A Response to McCoy’s “An Anti-Colonial Agenda for Decolonisation of Global Health”
Note: Here, Mark Padilla responds to David McCoy’s essay, “An Anti-Colonial Agenda for the Decolonisation of Global Health” (October 2023) which launched this Miami Institute forum on “What does it mean to decolonize global public health?” In the coming months, the Miami Institute is publishing global colleagues’ responses to McCoy’s essay and will conclude the forum with a virtual discussion among McCoy and respondents. Please join this discussion on what it means to decolonize global public health today.
Sometime in the mid-1990s, I had the opportunity to attend lectures by the late physician-anthropologist Paul Farmer, who later became the Executive Director of Partners in Health, the visionary organization that delivered both primary and ‘high-tech’ medicine to resource-poor populations in rural Haiti, Peru, Tanzania, Russia, and elsewhere.[i] I was a graduate student in anthropology at Emory University (Atlanta) at the time, and Paul’s perspectives on the fundamental right to health, to serving the “least of us” (he was, admittedly, deeply influenced by Latin American liberation theology), to inverting the historically-rooted power dynamics of global health– these were profoundly influential to me as I developed into a medical anthropologist. I remember, during one presentation to a small class of public health and social science students, he squeezed into a flip-up desk and reflected on how the history of colonial institutions, combined with the requisite anti-Haitian racism and slave-state extractivism, had magnified the devastating effects of the HIV and TB co-epidemics in contemporary Haiti. This intersection of the colonial past with the present state of health was a central thread in all of his work, informed by his early contributions to what some call “critical medical anthropology” (CMA). Paul is perhaps best known among anthropologists of my generation for his book AIDS and Accusation – first published in 1992 and whose subsequent editions remain core material in many anthropology and public health classrooms – where he takes his ethnographic evidence from the first wave of AIDS in Haiti and traces what he called the “fault lines” of global inequalities in health – those historical, colonial fractures that link disparate global institutions within a web or “assemblage” of wealth-generating practices in the service of a privileged, white, metropolitan minority.[ii] He views the social practices and processes he observes in his ethnographic work in Haiti through the lens of these global structures, which fundamentally shape the phenomenological experiences, social interpretations, and vulnerabilities to a new “germ” in a specific local setting.
Medical anthropologists such as Farmer, many of whom are deeply influenced by CMA, resonate well with Dr. David McCoy’s astute discussion, “An Anti-Colonial Agenda for the Decolonisation of Global Health.” By highlighting the “need to conceptualise colonialism in non-territorial terms” (p. 2), McCoy draws critical attention to the ways in which colonization has not disappeared as political movements toward independence have taken root, but rather has transformed into new forms of ‘coloniality’ that extend into the socio-cultural processes and global flows of relations – material, intersubjective, and embodied ‘ways of being in the world.’[iii] His call to decolonize global health, and his discussion of the global (mal)distribution of power and influence through neoliberal capitalist networks further draws our attention to the ways in which coloniality is continuously remade through the institutions that allow for “de-territorialised forms of contemporary colonialism” (McCoy, p. 3). His approach to global health “in three parts” provides a means of conceptualizing – for the purpose of our decolonizing work – the multifaceted ways in which global health itself is shaped by the coloniality of power, so that we can develop practical methods for doing this work.
McCoy’s references to the visionary potential of the Alma Ata Declaration, followed by its subsequent weakening due in part to concerns about its “unrealistic” implementation, recalls for me my early graduate reading in medical anthropology, when many ethnographers working in global health were both inspired and concerned by the practical implementation of Alma Ata-inspired primary health care programs in the Global South.[iv] Striving for rich ethnographic accounts of how local peoples were actually engaging with global health policies and programs, these scholars foregrounded the voices of the colonized and sought to interrogate the ‘cultures of global health institutions’ using institutional ethnography[v] from below, much in the way that McCoy is advocating today. Nevertheless, these early ethnographic accounts of global health institutions were not explicitly informed by Global South frameworks and thinkers such as Aníbal Quijano or McCoy’s own call to reinvigorate epistemologies aimed at deconstructing, criticizing, and dismantling the vestiges of coloniality in global health today. This call is ripe to bring renewed attention and practical intervention using community-engaged, experience-near, decolonial frameworks and methodologies that are informed by prior insights from the social sciences and beyond.
In one key lecture in honor of anthropologist Sidney Mintz[vi], Paul Farmer begins with a vivid and poignant ethnographic vignette of a Haitian woman with advanced untreated breast cancer who has been unable to obtain any semblance of care, and then traces the fundamental causes of her metastasized tumor to the colonial roots of Haiti through an extensive exegesis of the nation’s position in history. Students in my medical anthropology courses – many of whom hail from “STEM” disciplines such as biology and pre-med – are often initially puzzled at why Farmer views five hundred years of colonialism as relevant to understanding the woman’s tumor and her resultant suffering. As scholars take up McCoy’s call to decolonize global health, it is essential that we move toward a second phase of discussion regarding decolonial epistemologies and methodologies that can be used to critique and dismantle the effects coloniality in the institutions, social practices, and material flows that are constitutive of this ‘thing’ called Global Health.[vii] This requires not only creating new frameworks, but also rescuing and adapting the insights of prior work from across the social sciences and beyond. The techniques of institutional ethnography and the foregrounding of Global South voices, combined with structural frameworks that are attentive to historically emergent yet ever-shifting fault lines of colonial domination, seem to me to be tools that should be reinforced and replicated among students and practitioners alike.
-Mark Padilla
Dr. Padilla is Professor of Anthropology in Global & Sociocultural Studies and Director of the Research Network on Health and Society (REACH), within the School of International and Public Affairs, at Florida International University in Miami. Having conducted multiple NIH-funded studies relating to gender, sexuality, and HIV/AIDS in the USA and the Dominican Republic, Dr. Padilla’s research has more recently turned to considerations of climate change, disasters, and health care system resilience in Puerto Rico. His work has been published in multiple social science and public health journals, including Social Science & Medicine, the American Journal of Public Health, Global Public Health, Medical Anthropology Quarterly, Critical Public Health, and Culture, Health and Sexuality. In recent years, Dr. Padilla has incorporated visual methods into his research, including PhotoVoice and documentary films that have garnered dozens of film festival laurels. His complete bio is available here.
Endnotes:
[i] Farmer’s sudden passing in 2022 is a loss for global health, but has also renewed attention to his deep impact on generations of global health scholars and practitioners.
[ii] Farmer’s analogies throughout his body of work presage later discussions of assemblage theory, foregrounding how embodied experiences of individuals – indeed, subjectivity itself – is shaped by ‘far flung’ material and affective relations that can be traced through multi-sited ethnography. Such insights now have resonance in ethnographic practice beyond anthropology (e.g., see Ghoddousi and Page, 2020).
[iii] While his commentary does not explicitly mention him, McCoy’s approach here recalls Anibal Quijano’s discussion of ‘coloniality of power,’ which the latter describes as the system based on global capitalist domination of certain nations (or populations) by others, rooted in colonialism, but which also extends to the social, cultural, and cognitive level in contemporary societies with legacies of colonization. See a brief summary here.
[iv] A few key ethnographically-informed examples from this period are: Foster, George M. “Bureaucratic Aspects of International Health Agencies.” Social science & medicine (1982) 25.9 (1987): 1039–1048; Justice, Judith. Policies, Plans, and People: Foreign Aid and Health Development. University of California Press, 1986. Also see a more recent update from a CMA perspective: Pfeiffer, James, and Mark Nichter. “What Can Critical Medical Anthropology Contribute to Global Health? A Health Systems Perspective.” Medical anthropology quarterly 22.4 (2008): 410–415.
[v] Institutional ethnography requires studying “vertically”, e.g., how members are linked to institutional representatives and ideologies at different levels (e.g., bosses, supervisors, bureaucrats/administrators, outside regulators or policy makers). See one methodological example here.
[vi] Farmer, Paul. “Sidney W. Mintz Lecture for 2001: An Anthropology of Structural Violence.” Current anthropology 45.3 (2004): 305–325.
[vii] Indeed, the definition of Global Health is always open-ended, and offers an opportunity to consider what is included and excluded in its conceptualization and how its expression varies across time and sociocultural context.
