David McCoy’s decolonization analysis: All true, how much is new?

Note: Here, Ted Schrecker 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 in 2024 among McCoy and respondents. Please join this discussion on what it means to decolonize global public health today.

With one exception, explained below, I find little to disagree with in David McCoy’s analysis, and much to cheer about.  I offer only four observations.

First, frequent references to ‘global health’ do not always make clear the nature of the entity referred to.  Is it a field of study, an area of professional practice, a ‘community’, or a ‘complex’?  Or perhaps all of these, depending on the context?  This may seem like a terminological quibble, but it does matter.  The steps needed to decolonize global health as a field of study (see my third point, below) may be quite different from those needed to decolonize the ‘complex’, in the sense of the industry-government nexus that became scandalously evident during the Covid-19 pandemic and created, as David correctly notes, a situation of vaccine apartheid (Kavanagh & Singh, 2023; Sirleaf, 2022).  The former task demands restructuring institutions like universities and granting councils that support research and act as gatekeepers to positions that enable people to undertake it.  The latter demands, among other things, political contestation with institutions like the World Trade Organization, the U.S. Chamber of Commerce and the pharmaceutical industry that support broad intellectual property rights as an element of broader corporate political agendas that dominate trade (and, often, health) policy.  Needless to say, neither task is easy; neither are their analogues in other contexts, and some may not be possible in the current political environment.

Second, although as David notes the ‘movement to decolonise global public health recently emerged about three years ago,’ researchers and practitioners have long been providing data and analyses demonstrating the need for such a movement, and the evidence continues to accumulate.  The destruction of the Alma Ata agenda, which may or may not ever have been taken seriously by the governments that signed on to it, has been well described (Basilico, Weigel, Motgi, Bor, & Keshavjee, 2013; Brown, Cueto, & Fee, 2006; Cueto, 2004), and the architects of the selective primary health concept themselves conceded that it represented the best that could be done in ‘an age of diminishing resources’ (Walsh & Warren, 1979, p. 967).  This locution, as always, leaves aside the question of why resources are diminishing, and who is making that happen (Schrecker, 2013).  On that point, an explicit link between structural adjustment and ‘the legacy of colonialism and class formation’ was posited in a leading journal in 1991 (Kanji, Kanji, & Manji, 1991).  David is absolutely correct to foreground ‘[t]he de-linking of contemporary colonialism from the geography of nation states’: thus, a recent ethnography of water cutoffs in Detroit after a post-bankruptcy increase in service prices notes that ‘the water situation erodes perceived notions about the U.S. as a high-income, or ‘developed’ context, bringing traditionally “global” health concerns to the heart of an iconic American city’ (Whitacre et al., 2021, p. 1405).  The methodological point was made more than 20 years ago in terms of the need to shift from ‘territorial’ to ‘social cartography’ in development studies (Robinson, 2002, p. 1067).  Is it too impolite to suggest that decolonization’s current high profile results from the overdue acknowledgement of a large and long-standing body of social scientific work about the origins of health inequalities on the part of members of the medical profession, whose credo tends to be that doctor knows best, and what doctor doesn’t know is not worth knowing?   A sociology of how a long history of critical engagement was (re)discovered circa 2020 will be rewarding, and a great doctoral thesis topic it would be.

Third, decolonizing methods for studying global health and its social determinants is critically important for addressing the power asymmetries that are a target of the decolonization project.  A recent article makes a powerful case against hierarchies of evidence derived from biomedicine – specifically, the cult of the randomized controlled trial and systematic review (Ramani, Whyle, & Kagwanja, 2023).  Ramani and colleagues unfortunately refer to a range of non-epidemiological methods as ‘relativist’, which is a term of art in the relevant literature (cf. Susen, 2015) but likely to be misinterpreted.  Many qualitative social scientists and historians would probably not use the term.  I am also less than convinced by their emphasis on local knowledge, except in contexts that require attention to situation-specific program design and implementation.  What matters is the need for epistemological and methodological challenges to the ‘doctor knows best’ approach, which is entirely inappropriate for the study of influences on health in complex social environments.  As David Byrne has put it: ‘If policy makers want to know how a complex social world works then one thing is as sure as the fact that the sun rises in the morning – experimental approaches in general and randomised controlled trials (RCTs) in particular are about as much practical use in providing that information as is a chocolate teapot for holding tea’ (Byrne, 2011, p. 44).  I have enumerated a number of such challenges in a recent open-access article (Schrecker, 2023), but medically dominated research and teaching institutions make them extraordinarily difficult to mount.

Fourth, the one point on which I (partially) disagree involves the concept of anti-politics, specifically as deployed by Schedler.  David cites Schedler’s enumeration of four types of anti-politics: instrumental (technocratic), amoral (economistic), dogmatically moralistic, and aesthetic (focused on the symbolic realm).  The depoliticization of a range of key issues related to global health is vitally important, as illustrated by the Alma Ata case. (Such issues are ultimately about deciding who lives and who dies, and what could be more quintessentially political than that?)  At the same time, I am not convinced of the distinctive applicability of Schedler’s typology to the issues David raises.  Most importantly, Schedler simply neglects the crucial political economy question: cui bono?  Who benefits from the elision of power differentials and extractive economic relations from policy discussions of health, and from research agendas?  The question is important: such extractive relations are increasingly evident in domestic economies, and new cross-border manifestations will join existing ones, like the land grabs (largely neglected in global health research) to which David refers, in association with the material requirements of decarbonization.   Schedler’s perspective may have been plausible in 1997, but in the current hyper-polarized political environment in much of the world Schedler’s introductory claim that ‘[w]e live in antipolitical times’ reads as implausible, as indeed does his characterization of resurgent right-wing politics as antipolitics (Schedler, 1997, p. 1).     Rather, what we observe is a process in which more and more areas of life – think about women’s reproductive decisions, or public education in Florida and Texas – become the terrain of intrusive state action and intense, overtly and aggressively political conflict. It may be Schedler’s conception of politics that is problematic.  At the same time, the widespread disappearance from electoral agendas of issues like extreme concentrations of wealth in conjunction with expanded prevalence of poverty and precarity suggests that the correct question is: what issues figure in political discourse, what issues are elided or excluded from it?  And why?  (Spoiler alert: follow the money.)  The importance of agenda-setting was foregrounded in a classic text in political science (Schattschneider, 1960) that those concerned with the issues raised in David’s manuscript would do well to revisit.

Finally, I would like to draw attention to an important editorial and call for papers (deadline 1 January 2024) on ‘Anti-colonial and Post-colonial perspectives on public health and public health ethics’ by the editors of the journal Public Health Ethics (Dawson & Reid, 2023; https://doi.org/10.1093/phe/phad018).    

 -Ted Schrecker

Ted Schrecker is Emeritus Professor of Global Health Policy at Newcastle University and Fellow of the Global Policy Institute at Durham University. Schrecker is a political scientist by background, and moved from Canada to take up a position at Durham University in June, 2013 before transferring to Newcastle University with colleagues from Durham's School of Medicine, Pharmacy and Health in 2017. His research interests focus on the political economy of health inequalities, especially as they are affected by neoliberal globalisation, and on issues at the interface of science, ethics, law and public policy. For more detail about his research interests and publications, see https://www.ncl.ac.uk/medical-sciences/people/profile/theodoreschrecker.html

References

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