By: Tiffany Nassiri-Ansari | Published: September 20, 2022
On September 13, UNU-IIGH marked the launch of a new programme of work, Decolonising Global Health, with a webinar that presented the programme’s approach to decolonising Global Health. Three guest speakers joined the UNU-IIGH team:
- Danny Gotto, Founder and Executive Director of Innovations for Development (I4DEV)
- Anna Marriott, Senior Health Policy Advisor for Oxfam GB
- Sabina Rashid, Professor and Dean of the James P Grant School of Public Health, BRAC
This webinar was live-streamed on LinkedIn, Twitter, and YouTube, and a recording of the ninety-minute webinar is available on the UNU-IIGH YouTube channel.
The journey so far
The session was moderated by Emma Rhule, a senior researcher at UNU-IIGH who has been involved in the Institute’s development of this programme of work since its inception in early 2019. Decolonising Global Health takes as its point of departure the understanding that there is no single movement to decolonise global health; rather, a plurality of initiatives reflects the complex and contextual nuances of a reimagining of Global Health. However, a common point of unity has emerged: there is a clear push to move from theory to action and hold ourselves and each other accountable for the change we want to see.
Panel discussion: Colonialism and coloniality in global health
The panel discussion began with David McCoy, who set the scene with introductory comments on colonialism and coloniality and how Decolonising Global Health sees these forces intersecting with global health. He first identified the 1978 Alma Ata Declaration as a key point in global health history and as “an early manifesto of global health” that also called for a decolonised world. Crucially, the Declaration emphasised the need for a New International Economic Order, the importance of culturally-appropriate healthcare, and true international cooperation and partnership. However, McCoy recounted that Alma Ata was “quickly undermined and replaced by the narrow and conservative ideology of selective primary healthcare,” which hampered rather than facilitated progress toward fair and sustainable development.
While Alma Ata serves as “an important and historical touch point” for contemporary conversations about decolonising Global Health, McCoy highlighted the importance of a working definition of colonialism. For Decolonising Global Health, colonialism is defined in two parts: firstly, it refers to the domination and subjugation of one group (or groups) of people by another; secondly, and relatedly, it involves exploitation, extraction, and appropriation of resources and wealth. Based on this definition, colonialism may be conceptualised as a multifaceted phenomenon that: occurs within, between, and/or across countries; operates at a local or global and transnational level; and manifests in both overt, explicit, and brutal ways and subtle and covert way, sometimes even hidden in the guise of charity or aid.
The term neocolonialism is also crucial for two reasons: first, to draw attention to the fact that colonialism can occur indirectly through economic structures and systems without direct colonisation and occupation, and secondly, to dispel the notion that we live in a post-colonial era when in fact, neoliberalism reigns in a world of “staggering, eye-watering, and uncivilised levels of inequality”.
Behind the engines of exploitation, extraction, and appropriation, one also finds coloniality, “ideas, beliefs, and narratives that help legitimise and sustain colonialism”. Many different ideas, beliefs, and narratives are used to sustain or justify colonialism. Of particular importance have been racist ideas, beliefs, and narratives. Racism may be subtle, or it may manifest as some people being dehumanised or subhumanised as a pretext for extreme brutality, violence, and even genocide.
McCoy also described a gendered form of colonialism, in which ideas, beliefs, and narratives that promote gender inequality have sustained the domination and subjugation of women by men, including their economic exploitation, as evidenced by the disproportionate amount of unpaid and unvalued care work done by women all across the world. Colonialism and coloniality also exhibit an intersectional dimension, with many clear instances in which racism and sexism combine to produce social patterns of exploitation.
Finally, McCoy argued that a contemporary form of coloniality is the ideas, beliefs, and narratives of the dominant neoliberal policy paradigm that has “produced the massive inequalities we see today and enabled the concentration of power in the hands of the few”. There is a deeper conversation to be had about the history and ideology of neoliberalism, but for this discussion, McCoy highlighted two relevant ideas often found in mainstream economics: the positioning of billionaires as ‘wealth creators’ as opposed to ‘wealth takers’, and the claim that the strengthening of private intellectual property rights (over the past twenty years) has encouraged scientific innovation. He branded both as “false economic ideas which have instead enabled colonial relationships to thrive”.
McCoy also pointed out the “long history of interconnectedness between colonialism and the ecological crisis”. It is a colonial mindset, he argued, which positions the planet as a resource to be plundered, pays no regard to destroying the habitat of other species, and fails to understand – and has at times even destroyed – the knowledge systems and philosophies of Indigenous cultures which prioritise living in balance with nature. There is also a temporal dimension to this mindset, which McCoy referred to as “intergenerational colonialism whereby present and past generations have essentially stolen from future generations”.
McCoy ended his presentation by posing a set of key questions: How do colonialism and coloniality relate to the global health system and community? Which aspects of the system and community need to be decolonised? And how can the movement shift from discussion and analysis to practical change? In launching this programme of work, UNU-IIGH hopes to engage with others, encourage debate, and provide a safe space for uncomfortable and risky conversations, all toward catalysing action in a progressive direction. To that end, Decolonising Global Health has set out three intersecting dimensions: colonialism within global health (power asymmetries within the system), colonisation of global health (domination of and control over the systems and structures of global health dominance), and colonialism through global health (mechanisms by which global health acts as a means to exploit, extract, and appropriate).
With the conceptual underpinnings thus outlined, McCoy handed over to Sabina Rashid, whose remarks centred on the practical interpretations and applications of these concepts, particularly in her work as Dean of BRAC’s James P. Grant School of Public Health. Rashid recounted how the initial set-up of the school took a cut-and-paste approach, in which curricula from an Ivy League were introduced wholesale to the school. While some elements of the curricula were useful, there were significant disconnects between the curricula and the contextual realities of Bangladesh and a lack of context-specific competencies.
One of the issues Rashid identified was a colonial legacy of hierarchical understandings of what to value, who has knowledge, and who is given value for that knowledge. She noted that in the last ten years, there have been significant changes and shifts as the school quickly realised that there was a need to move away from cut-and-paste curricula to bring in more considerations around culture, history, and traditional understandings of the body’s illness and health. There was also an increase in community engagement, allowing students to spend time in rural areas and slums where they could learn from communities and contextualise public health through a more holistic approach which considers the role of housing, water, and sanitation in disadvantaged communities.
Rashid also identified critical problems at the faculty level, where fixed understandings of who is worthy of the professor title can impede improvements in teaching. The school has joined a growing group of others in engaging practitioners to co-teach and facilitate classes, drawing on their implementation experience and expertise. Rashid affirmed that her primary concern as Dean is preparing students to play a role in improving health while challenging false conceptions of what a “good” public health education looks like.
Finally, she touched on the default approach to public health as a biomedical discipline, which she linked to the Western valuing of biomedicine; this does not align with the pluralistic and indigenous notions of body, self, and illness found in many parts of the world. Going beyond a biomedical notion of public health facilitates the creation of contextual solutions better suited to local communities, as opposed to the policy recommendations that emerge from what Rashid referred to as “development tourism“. In closing, Rashid emphasised that beyond a positioning of the Global North versus the Global South, the focus must be on understanding and valuing different forms of knowledge.
Rashid was followed by Danny Gotto, who was educated as a medical practitioner and has since worked in various settings within the global health ecosystem. A common thread unifying his experiences, Gotto said, was “the story of Africa” as relayed in a series of compelling figures. Despite accounting for 17% of the global population, the continent of Africa carries a disproportionately higher burden of disease and higher levels of hunger and poverty. With its abundance of natural resources, Gotto rejected the excuse of resource scarcity as a cause of Africa’s development indicators early in his career and pushed for a better explanation. Over time, this led him to discourses on coloniality and colonisation and the role of power, externalities, and vulnerabilities. “I discovered that the game is not for us. The system was never designed for us, ” referring to systems and structures that continue to perpetuate dependence on foreign aid, often failing to address root causes.
Instead, Gotto described how structural adjustment programmes led to the defunding of public health services and the deindustrialisation of local enterprises. Within the health sector, this led to increased numbers of migration among health workers, such that by the time the HIV epidemic hit its peak in 2000, the Ugandan health system was “crumbling”. In the context of this collapse, INGOs would dip in and out, “cherry picking diseases of interest to them” and creating siloed approaches which excluded wide swathes of the population. Gotto remarked that of the few disease-based programmes established, most employed interventions designed in American cities and implemented in African contexts with no adjustments. Furthermore, the operations of INGOs added to the exodus of health professionals from the public sector, with most electing to work for INGO programmes which offered better salaries and more interesting opportunities. However, the temporary nature of these programmes, which Gotto described as a five-year model of “invest, then move out,” has subjected health professionals to a pattern of moving from one project to another.
These are signs of a weakened health system, despite pledges from many international actors and donors to “build” or “strengthen” these same health systems. The writing on the wall became especially pronounced in the mad scramble for COVID-19 vaccines; after decades of programmes that claimed to build capacity within African health systems, the continent produced only 1% of the vaccines it used. Gotto suggested that rather than a lack of technical know-how, perhaps the true cause of this situation was more neoliberal in nature; rather than waiving IP rights to allow Africa to produce vaccines, pharmaceutical companies were more interested in selling Africa the vaccines.
Fellow panellist Anna Marriott added to his comments on the vaccine divide, drawing on her experiences as part of the People’s Vaccine Alliance which called for vaccines to be viewed as a global public good. She recounted the progress made in 2021 when a proposal led by South Africa and India managed to secure interest and support from governments, scientists, and high-level advocates across the globe – including the White House. However, this came to an abrupt halt when pharmaceutical executives and their sponsored experts hijacked the discussion by perpetuating the racist claim that “letting developing countries manufacture vaccines would be a problem [because] they wouldn’t get it right, they don’t know how to do it”. Marriott noted that this narrative was championed by some of the richest people on the planet, highlighting that “inequality in health has deep roots in inequality in power and wealth, and the abuse of that power for the benefit of the few at the expense of the many”. This false narrative reached its peak when Pfizer and Moderna were making an estimated USD1000 per second in profits, and the world had just anointed nine new vaccine billionaires. “Decisions about who lives and who dies from COVID-19 were outsourced to the CEOs of Big Pharma,” Marriott pointed out, while “a common sense, fair, and honestly not very radical solution… was put out of reach because of an unfathomable power differential”.
Marriott described Oxfam’s work on structural inequalities in global health and the wider development architecture which has entailed tracking the impact of a new era of donor-driven privatisation of healthcare, as well as investigating World Bank-supported public-private partnerships (PPPs) in health. In Lesotho, for example, more than half of the nation’s entire health budget was diverted to deliver 25% returns for private investors. This “notorious and unsustainable PPP collapsed at the height of the pandemic,” at which point private hospitals either shut their doors to desperate patients or charged hyper-inflated prices. Tracing the “complex web of financial actors investing in these and other exploitative hospitals in the Global South” led Oxfam to discover that many of these hospitals were directly funded by the governments of the UK, France, and Germany, as well as the World Bank via its development finance budget.
Since the rise of PPPs, Marriott has observed with concern the “ever more chaotic proliferation of opaque and unaccountable partnerships [as well as] ever more blurred lines between decision-makers and those engaged in unethical profiteering and wealth extraction”. She offered up the striking example of COVAX, which had as its self-appointed designers and leaders “the CEOs of two global health PPPs… without any meaningful participation from the countries intended to benefit”. As a result, “billions were paid to pharmaceutical giants for contracts with zero transparency and no accountability, including when those corporations failed to deliver”.
“Driving, shaping, and financing” much of this change in the global health architecture is a philanthrocapitalist “that so many in our community avoid talking about,” Marriott commented before naming Bill Gates and questioning his “unbridled, unaccountable influence” within global health. This influence could have been exercised to support a temporary suspension of pharmaceutical monopolies which would undoubtedly have had a significant impact over the course of the pandemic and led Marriott to challenge the amount of power that “the opinion of one extremely wealthy, unelected man from the US” holds over global health.
Marriott concluded that the “comprehensive, contemporary” version of colonialism framed by UNU-IIGH was “a valuable lens through which to critique and assess global health”. In her opinion, the movement to decolonise global health must not stop at fighting for a seat at the decision-making table; rather, it requires “removing others with vested interests from that table, understanding and challenging how inequality has shaped and influenced the decisions on offer at that table, [and] exploring and interrogating… if that table should even exist”. A colonial lens makes clear the need for new rules that address corporate concentration, uphold the right to health above the “obsession of protecting property, [and] end profiting from pain”.
Finally, Marriott framed this discussion as one that “must be about new voices,” including a diverse array of health and economic thinkers and practitioners from across the South as well as working class and diverse communities across the North. These are the voices that those who are already sat around the table must include “in every space for decision-making in global health”.
Q&A: Colonialism and coloniality as a global struggle
How much have domination and subjugation influenced internalised mentalities when it comes to who is exploited and who exploits?
Rashid began by linking internalised coloniality with notions of power, privilege, and politics. Speaking specifically on curricula and research, she identified patterns of exploitation and domination in the continual devaluation of “our own kind of research and curricula”. In describing how she and colleagues “fought back and changed the system” at their school, she noted that “unfortunately, you have to be part and parcel of the system” to enact change from within. She also pointed out that it takes a lot of courage to speak up due to fear of reprisal and that those in positions of power must use their voices from whatever positions they find themselves in.
Can you speak more on the risks people face when they essentially put their head above the parapet? And on a related note, for those already in positions of privilege and working with powerful global health actors, what actions have you seen taking place to change the narrative?
Gotto returned to the concept of internalised colonialism to share his own experiences of speaking out, relaying how “even your comrades within countries who are benefitting from the system look at you as a saboteur” for fear that speaking out will cost them what little resources are made available by INGOs in the form of employment and procurement of ART amongst other things. The struggle for those trying to change the narrative is whether to continue speaking out in the name of the greater good, even if it risks the “bread and butter for their team”.
On the topic of speaking out and changing the narrative, can the decolonisation of global health really be led and implemented by the same people that caused colonisation? What does it mean to have a decolonising movement with large representation from the Global North and traditional power holders?
McCoy framed the struggle against colonialism and coloniality as a global endeavour, one which “needs to be joined by people in both the geographic North and South as there are people in Europe and North America who are also subjugated by a global political and economic system that is unjust and unfair”. The key distinction for McCoy is neither country of origin nor residence, or racial and ethnic group; rather, it is about champions of justice and fairness versus individuals “who are happy to take more than they should, to appropriate, extract, and exploit”. The geographical boundaries are increasingly blurred with a rising number of billionaires in Africa, Asia, and Latin America, and it is this concentration of power and wealth that must be fought against by a broad coalition across the globe.
Continuing with the theme of global struggles, what can be done now to increase access to COVID-19 vaccines in the Global South, and perhaps more importantly, to ensure that we don’t find ourselves in the same position should we face another pandemic of this ilk or similar situations in which global public goods will be vital?
Marriott highlighted that while viable alternatives exist to prevent a similar scenario from unfolding in the future, these vaccine development and knowledge-sharing models have received considerably less funding and priority. However, some actors have forged ahead in their mission to treat vaccines as a global public good, such as the Texas Children’s Hospital Center for Vaccine Development which is developing patent-free vaccines and working with manufacturers in places that have been denied access to vaccines. There is also a WHO-led MRNA Technology Transfer Hub in South Africa, intended to serve as a Global South-led model for developing MRNA technology not only for COVID-19 vaccines but also vaccines for other diseases of concern in the Global South. Such efforts are not rare, but they can often be foiled – as in the case of the AstraZeneca vaccine, in which scientists advocating for patent-free waivers were overpowered by pharmaceutical corporations vying for exclusive manufacturing access. To prevent future losses, political capital and support are crucial; the pandemic treaty currently under negotiation serves as a potential battleground for alternative models of vaccine development and production.
In terms of the current vaccine divide, Marriott passed over to Gotto to draw from his observations in the Ugandan context. Gotto shared that a cost analysis found a clear lack of resources to sustain vaccine procurement; long-term access to COVID-19 therapeutics is also a challenge and points to an overall need to ramp up pharmaceutical production capacity in Africa. The African Union is leading the way by establishing pharmaceutical hubs in different parts of the continent, such as Egypt, Kenya, Senegal, and South Africa, and it is hoped that this will significantly lower the financial burden of vaccinations.
McCoy offered some thoughts on alternative financing models to develop and manufacture vaccines, stressing the importance of “finding ways to create more public finance and a greater degree of political support for the notion of public interest”. Fundamental to this is the regulation of the financial sector, as the financialisation of the global economy in recent decades “has resulted in a financial system that is undemocratic, not properly accountable, and concentrates huge amounts of power in the hands of private financial institutions”. A non-functional tax system – at both the local and global levels, enabled by non-transparent international banking and accounting arrangements – is also in desperate need of reforms to end tax avoidance and abuse. These are practical first steps toward generating “the public finance required to fund and deliver more public goods and services”.
Moving into governance and accountability, both in terms of engaging national governments in the decoloniality agenda but also addressing the imbalanced contributions of private and philanthropic money to the sector, what are some practical next steps to reckon with the governance and accountability of the global health architecture?
Marriott stressed that “we cannot isolate what needs to take place in global health from what is going on in the wider economy”. She echoed McCoy’s call for wealth and corporate taxes, not just to raise revenue for public goods but to curtail the influence of “incredibly powerful actors”; a maximum wealth line was also suggested to restrict the amount of power any given individual can wield within Global Health. However, this is only one element of the “absurdly chaotic and opaque” health financing system that blurs the lines between decision-makers and those profiteering from said decisions. Marriott called for a shift to truly democratic multilateral institutions by returning power to the WHO and other democratic spaces and “reminding ourselves of the logic of conflicts of interest” and the need for boundaries. This is just a first step in the process of re-examining the global health architecture as a whole, which “requires us to go beyond demanding a seat at the table… to actually re-evaluate who has power within those institutions” and call for a redress of that power.
Finally, thinking about civil society and the role of community groups as potential accountability drivers, can you talk about how you see accountability within the global health system from that perspective?
Drawing on her experiences of working with communities as part of contextualised curricula, Rashid positioned community groups at the heart of social justice, equity, and improved health, challenging the legacies of colonialism and the forces of coloniality to remain focused on local contexts. However, the onus cannot lie solely with community groups; Rashid stressed the need for everyone to “deconstruct and dismantle models from the positions we’re in”. For her, this has taken the form of creating relevant curricula, building competencies and capacity, and sustaining engagement in a fair way.
Rhule closed the Q&A session with a reflection on the “fantastically complex” nature of the global health ecosystem, put on display here by the rich variety of questions and topics, and commenting that the interlocking nature of the many parts within this ecosystem necessitates a multi-pronged approach to reimagining global health that covers accountability, governance, incentive structures, and more.
Rajat Khosla, the Director of UNU-IIGH, closed the webinar by thanking panellists and participants for a “sobering and thoughtful conversation”. Khosla branded the decolonisation of structures, systems, and processes related to global health as an “imperative, not an optional add-on” in the face of today’s global health system, which lacks equality, diversity, inclusivity, and “the tools to address the challenges of our lived realities”.
Khosla also highlighted “the complex and intersecting webs which continue to exclude a diversity of voices to maintain the hegemonic control which leads to an unjust and unequal global health agenda”. He underscored the need for change at a substantial rather than rhetorical level, with the aim of rethinking and rebuilding systems across the board. Achieving a decolonial global health will only be possible through a collective effort. UNU-IIGH will build on existing relationships with scholars, civil society, and sister agencies to work toward a transformational shift within global health and invites other organisations to join us on that journey.
Acknowledgements: The Decolonising Global Health team wishes to thank our colleagues and collaborators, both past and present, for contributing to this work.