BERLIN — Earlier this year, students from Harvard University's school of public health, spurred by a curriculum they found short on political and historical context, organized a conference on “decolonizing” global health.
Selling out in just five days, it tapped into rising discussions on the issue. For example, when the London School of Economics advertised for an African health systems expert based in the United Kingdom in February, it prompted a Twitter discussion around the hashtag #decoloniseHPSR [health policy and systems research]. A session at the African Health Economics and Policy Association conference in Ghana in March saw similar calls.
“What we are seeking to grapple with when we draw on decolonial theory intentionally is to be able to really understand structural issues and the implications of structural issues on people’s everyday reality.”— Lance Louskieter, doctoral candidate, University of Cape Town
"We're at the cusp of a larger conversation that needs to happen," said Dr. Renzo Guinto, a Filipino physician and doctoral candidate at Harvard, who has written about decolonizing global health.
That conversation is considering both the direct legacy of the colonial era on health systems and the way that patterns from that era are reproduced. "But we cannot take the trajectory of a long, winding conversation," Guinto said. "These issues are right on our doorstep."
The meaning of ‘decolonization’
Advocates of the perspective identify colonialism's influence everywhere from board rooms in Geneva, Switzerland, to Ebola treatment wards in the Democratic Republic of the Congo.
The outbreak declared there in August 2018 is spreading at a record pace. Despite the introduction of a new vaccine, at least 1,121 people have died of the disease. Yet in some areas, Congolese have met response efforts with violence — burning down clinics and even attacking and killing health care workers.
Communities have expressed frustration with a response that upends traditional systems of care and isolates patients from their families. And they are confused about why Ebola merits an international response, where other diseases that have plagued their communities have not.
Speaking with Devex, Dr. Joanne Liu, international president of MSF, says communities in DRC have been left behind, creating failure in the Ebola response — and blames a growing security mindset where countries only choose to assist when they feel threatened.
The international organizations shoring up that response are grappling with this reaction. In a March statement, Dr. Joanne Liu, president of Médecins Sans Frontières, acknowledged that "choices must be given back to patients and their families on how to manage the disease." That includes integrating diagnosis in traditional health facilities, rather than creating a parallel system, and providing families who ultimately decide to care for patients with the resources to do so as safely as possible.
In instances where health interventions are imposed on low-income communities, the neocolonial influence is more obvious, observers said. But advocates argue that colonialism is also bound together with a political and economic system that prioritizes unfettered access to the markets of the global south — no matter that the expansion of some industries, such as sugary drinks and processed foods, has been linked to skyrocketing rates of noncommunicable diseases in those countries.
The latter was prominent at the Prince Mahidol Award Conference in Thailand in January and February, which gathers the global health community to discuss policy issues. Activists there were vocal about their frustrations that the onus has been put on lower-income country governments to solve the problem, rather than on the industries that are helping to create it.
The issue of colonialism is also present in discussions about who controls funding, who attends conferences, where they are held, how research teams are structured, and whose books are included in syllabi.
While participants in these efforts work hard to improve health systems around the world, Sudipta Saha, one of the organizers of the Harvard conference, said the usual approaches reinforce a system that disregards or downplays the perspective of the global south.
The problem with ‘global health’
While the idea of decolonizing global health has gained prominence recently, it is not new. Discussions about the impact of the colonial legacy on health systems began with the end of the colonial system. And questions of neocolonialism in the work of global philanthropic organizations already swirled around The Rockefeller Foundation more than a century ago.
Guinto places it alongside discussions about the role that race and political economy play in the delivery of health services. Positioning these issues in a colonial context, though, "has a more activist tone," he said. "It's apart from the more neutral social science style of, 'Let's describe and analyze.'"
It is also not a movement, but a loosely-connected discussion among academics, activists, health practitioners, and others, that is taking on new urgency, as actors look to identify and correct imbalances in power. Within the discussion itself, there is a divergence over what is being critiqued.
Much of the conversation has centered on decolonizing global health, which can mean reversing the immediate legacies of colonialism, including the lack of investments in health systems and robust research institutions in former colonies. But it can also mean dismantling “global health,” a term that often stands in for the system of international institutions and donors that govern the public health agenda and control levers of power.
This western-dominated system “dictates and sets the policies and the practice of global health in the field," said Rachel Thompson, a health policy researcher. It is not so difficult to trace a lineage to tropical medicine and its efforts to protect colonizers from the diseases they encountered in their conquests; just as critics say one of the reasons Ebola is seen to require an international response is the fear it could spread to rich countries.
“Global health” is a term that really reflects only one viewpoint, advocates say — of the developed world gazing on the developing.
But colonialism can also manifest within local health systems and institutions, said Lance Louskieter, a doctoral candidate at the University of Cape Town, who organized a February webinar on the issue. Louskieter offered examples such as health structures that disempower nurses, even though they provide the bulk of medical care; and community-based NGOs that focus on behavior change without confronting the structural reasons that contribute to unhealthy decisions.
“What we are seeking to grapple with when we draw on decolonial theory intentionally is to be able to really understand structural issues and the implications of structural issues on people’s everyday reality,” Louskieter said.
Though activists agree there can be no single solution to addressing the colonial influence on health systems, the way forward is still under discussion.
The organizers of the Harvard conference have leveraged their success to build a consortium of global health programs. The idea is that the gathering might become an annual event that rotates between schools. Within their institution, they are discussing expanded syllabi and new seminars.
"It's not a series of checked boxes, though, like once you have a decolonized syllabus or five or more women of color, you are officially decolonized," Amina Goheer, one of the organizers, told Devex. "It can't be so reductionist."
But their approach offers a guide for people at a variety of global health-focused institutions to at least open discussions about how they perceive colonialism within those organizations.
Outside the global health apparatus, awareness is also fundamental. In her research and practice, Dr. Leanne Brady, a doctoral candidate and one of the organizers of the Ghana session, said she has learned to "make room for different perspectives. There are many different ways to think about something and to work with those multiple perspectives, rather than just create a hierarchy," she said.
There are also opportunities to engage people, advocates said, so when an incident occurs such as LSE’s posting of a London-based job to build an Africa-centric network of health researchers, there is a cadre ready to ask why and propose alternatives. Beth Kreling, a senior policy fellow at LSE's department of health policy, told Devex the position was ultimately filled at the university but that it would be part of a larger project that would see the bulk of the research capacity based in Africa.
On a national level, Thompson said the shifting dynamics of global health might spur these conversations along. Specifically, the international push for universal health coverage — headlined by the upcoming United Nations high-level meeting in September — tasks countries with setting their own health priorities, which is an opportunity for decolonizing, she said.
Countries might be freed to more critically examine international approaches to health care that have been handed on to them, and push for solutions that better accommodate their situation.
In sub-Saharan Africa, for instance, the global community has championed long-lasting depo provera as a favored form of birth control, despite concerns that it might increase a woman’s risk of acquiring HIV. In constructing a basic benefits package, governments may decide to subsidize forms of birth control that do not come with the same risk. They will be able to make domestically minded decisions about a range of services, Thompson said, “throwing up a lot of interesting discussions.”
Guinto added, though, that countries transitioning to UHC are getting plenty of guidance, if not financing, from the existing international order.
"We already know there are things that are wrong with this global health architecture and this global health system," Guinto said. "And there are some ideas of what to do. But hopefully starting at the colonial discussion will lead us to different answers."