An Anti-Colonial Agenda for the Decolonisation of Global Health
Note: With the below essay, David McCoy launches the Miami Institute’s forum on “What does it mean to decolonize global public health?” In the coming months, the Miami Institute will publish 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.
Background
In 1978, a major conference on Primary Health Care organised by the World Health Organization produced the landmark Alma Ata Declaration. Despite not including the words colonial or colonialism, the Declaration was quintessentially an anti-colonial and de-colonial expression of global health. For example, in demanding urgent action to protect and promote the health of all the people of the world, it emphasised the need for an equity-oriented, bottom-up and community-empowering approach to health care that used culturally appropriate technology and adopted a developmental approach to health that included access to clean water, sanitation and nutrition. It also called for a New International Economic Order, peace and ‘true’ independence’ for the new nations of the Global South, echoing many of the anti-neocolonial aspirations of the non-aligned movement of developing countries that emerged in the 1950s and 1960s.
However, despite being widely acclaimed, within a few years, the Declaration was criticised and challenged for being utopian and unrealistic. And eventually, the comprehensive approach of Alma Ata was effectively replaced with an approach to health in developing countries that was largely conservative, de-politicised and focused on a narrow selection of ‘cost-effective’ bio-medical interventions.[i] Moreover, instead of the idea of global health evolving to include a fair international economic order, the emerging complex of global health actors and institutions came to resemble more and more an extension of the aid programmes of wealthy countries and a mechanism by which to mitigate the hollowing out of health systems in developing countries by structural adjustment programmes in the 1980s and 1990s.
While expanded access to life-saving medical interventions have reduced mortality in many countries, the impacts of this selective approach to health improvement are inevitably limited. Today, millions of people still lack access to essential healthcare and adequately-staffed health systems. Many measures of poverty and health inequality are worsening, and the global experience of Covid moreover exposed deep structural fault lines in the political economy of health. Meanwhile, health gains in the poorest countries over the past few decades are fragile and face being reversed by climate collapse, war and anti-microbial resistance.
It is within this context that a movement to decolonise global health recently emerged about three years ago. Sparked by student-led campaigns against the celebration of imperialists and slave traders in public spaces and the upsurge of Black Lives Matter protests following the murder of George Floyd, there have been numerous calls from within the global health community to challenge the dominance and exploitative practices of western/white/eurocentric actors and, relatedly, western/white/eurocentric knowledge systems within global health.[ii] While these calls have tended to focus on the unequal power relationships between actors from wealthy countries and their counterparts in poorer countries, the experience of a ‘global vaccine apartheid’ during the pandemic has also raised questions about corporate power and globalised forms of exploitation and wealth extraction that transcend the Global North-Global South divide.
This article argues for an approach to decolonising global health that challenges coloniality and unequal power dynamics within the global health complex, as well as the manner in which the global health complex enables or legitimises contemporary forms of colonialism across the wider global political economy.
Colonialism
At its core, colonialism is about the large-scale and systemic misappropriation and extraction of resources and wealth. While it is often associated with the direct conquest, control or occupation of lands or trading routes by a foreign power, it may be practiced indirectly as demonstrated, for example, by the United States’ ability to shape the global financial and economic system in its favour without having to manage a large territorial empire. Fundamental to colonialism is a power imbalance that allows for relationships of domination/subjugation and exploitation/subservience.
While territorial control remains important with, for example, land grabs having proliferated in recent years[iii] and while patterns of wealth extraction can be mapped according to the power differentials between countries and regions, there is a need to conceptualise colonialism in global (trans-national) and non-territorial terms. This includes the trans-national colonisation of globalised markets, the colonisation of virtual digital spaces[iv], and the legally-mediated colonisation of knowledge through the expansion and strengthening of private intellectual property (IP) rights. Contemporary colonialism also includes a more central role for private financial institutions that have control over vast amounts of hyper-mobile finance capital, giant monopolistic TNCs covering vast swathes of the global economy, and banking regimes that allow industrial-level scales of tax avoidance.
The manifestations of contemporary colonialism are evident in the increasingly skewed pattern of wealth distribution across the world, particularly in terms of the new wealth generated in the past four decades. Today, by one estimate, 10 men own more wealth than the poorest 3.1 billion people and an increasing share of GDP goes to TNC profits while workers experience falling wages, deteriorating working conditions and increasing precarity.[v] The de-linking of contemporary colonialism from the geography of nation states can also be seen in the simultaneous growth of billionaires in the Global South and poor people in the Global North.
Another key part of colonialism is the construction of ideas and narratives to enable and legitimize systemic exploitation and wealth extraction. Racist ideas, including those targeting particular religions or ethnicities, were central to the most brutal expressions of colonialism (eg. genocidal acts against indigenous populations and the trans-atlantic slave trade) and to simultaneously portraying colonialism as a moral and civilizing act towards ‘inferior’ cultures and races. While racism is still a factor in contemporary forms of colonialism, other ideas and narratives have become important.
Of particular note are various neoliberal ideas and narratives that have been successfully propagated through a network of well-funded lobbyists, think tanks and academic units.[vi] These include false claims about the social benefits of unregulated markets, competition and private IP rights, coupled with fear-mongering about redistributive tax policies and corporate regulation harming society and hindering innovation. They also include claims that perpetual economic growth is possible on a finite planet and that a technologically-driven form of ‘green capitalism’ can avert climate disaster. And just as European colonisers were portrayed as white saviours, so are today’s billionaires and corporate behemoths, with their philanthropic foundations, portrayed as not just as benevolent wealth creators but also as people whose entrepreneurial qualities can be used to solve the world’s problems.[vii]
Decolonising global health in three parts
Any movement to decolonise global health must thus consider both historical and contemporary forms of colonialism mediated through unequal relations between countries, as well as the systemic exploitation and extractivism rooted in the financialised and de-territorialised forms of contemporary colonialism. To do so, the global health community may consider a three-pronged agenda for challenging colonialism as follows.
Colonialism within global heath
First, it must challenge unequal, unfair or exploitative relationships between actors working within global health. Current discussions have centred on relationships between actors with power and privilege (usually referenced with labels such as ‘Global North’, ‘western’, ‘developed’, ‘European’ and ‘high income’) and those who are vulnerable to being subjugated and exploited (usually referenced with labels such as ‘low-income’, ‘developing’ or ‘Global South’). Various new guidelines and initiatives aimed at preventing exploitative behaviour and promote should produce not just more respectful and equal partnerships, but also more appropriate and contextually-relevant research and project implementation and thereby better outcomes. Critically, efforts between academics and NGO actors to decolonise their relationships, behaviours and attitudes will have limited impact unless the major funders of global health – mostly based in the Global North - are also challenged for perpetuating or furthering colonial relationships. It is they who hold most influence over the design and shape of global health research, programmes, projects, conferences and meetings, and who ultimately determine the shape and nature of hierarchies within global health.
The colonisation of global health
It follows then that the dominance and colonisation of global health itself by certain actors must be challenged. This includes challenging the dominance of states who provide large amounts of funding to key global health organisations and initiatives, as well as the of powerful private actors that have become major funders and influencers of global health. This must also entail a revival of the underlying approach of Alma Ata and a challenge to the ‘anti-political’ narratives that ignore the social and political drivers of ill health and inequality and also embed commodifiable knowledge and proprietary technologies with which to extract wealth within global health policy.[viii] An associated challenge will be to ensure that the public-private partnerships and financial instruments that have weakened multilateral systems of governance and created new decision-making spaces are not unduly influenced or captured by powerful commercial actors with conflicts of interest.
Colonialism through global health
Finally, a movement to decolonise global health must also challenge all instances of the health sector being integrated into broader systems of contemporary wealth extraction and exploitation. As a trillion-dollar industry, there are many opportunities for colonialism to be practiced through global health. One example is the eye-watering levels of profiteering by monopolistic corporations during a pandemic that produced a whole cohort of new billionaires while leaving hundreds of millions of households economically devastated.[ix] Other examples elate to the financialization of health systems and the growing numbers of under-regulated and highly extractive corporatized hospitals (sometimes generating profits with a brutality not dis-similar to that seen in 19th-century colonialism)[x], and the expansion of digitalised modes of healthcare that will not only grant powerful Big Tech companies immense power and opportunity to extract profits, but also threaten the rights, privacy and freedom of individuals everywhere.[xi]
Conclusion
Calls to decolonise global health are welcome and important. There is all manner of unequal, unfair and out-moded relationships within global health, especially between actors in the Global North and Global South, that must be challenged. Similarly, attitudes of white or western superiority must be replaced with non-racist, multi-cultural and inclusive attitudes to global health practice. This article, however, stresses the importance of challenging the highly financialised and corporatized forms of contemporary colonialism and the forms of empire that have expanded especially in the last four decades of neoliberal globalisation. In doing so it argues that global health must not only correct traditional power imbalances within global health, but also challenge the colonisation of global health itself and oppose unethical and abusive profiteering occurring through the practice of global health.
-David McCoy
David McCoy is a public health doctor who was until recently, Professor of Global Public Health at the Institute of Population Health Sciences within Queen Mary University London in the UK. Now based in Malaysia, McCoy now works for the United Nations University International Institute for Global Health as Research Lead – Evidence to Policy. McCoy has an M.Phil in Maternal and Child health and a doctorate from the London School of Hygiene and Tropical Medicine.
Endnotes:
[i] The history of Alma Ata’s decline and its replacement with a selective, conservative and technological approach is well described in Sanders D, 2023. The Struggle for Health (2nd Ed). Oxford: Oxford University Press. The charge against Alma Ata was led by the Rockefeller Foundation and supported by technocratic and econometric arguments in favour of the WHO focusing on the delivery of a few high-priority and ‘cost-effective’ medical interventions. This approach (that excluded Alma Ata’s emphasis on socio-economic development, multi-sectoral planning and community empowerment) was also adopted by UNICEF’s child survival programmes in the 1980s and then amplified by the World Bank through the structural adjustment programmes that were imposed on many developing countries in the 1980s and 1990s.
[ii] See for example: Ahmed AK, 2020. Rhodes Must Fall: How a Decolonial Student Movement in the Global South Inspired Epistemic Disobedience at the University of Oxford. Afr Stud Rev; 63(2):281–303 / The Lancet, 2020. Medicine and medical science: Black lives must matter more. https://doi.org/10.1016/S0140-6736(20)31353-2 Khan M, Abimbola S, Aloudat T et al, 2021. Decolonising global health: a roadmap to move from rhetoric to reform. BMJ Global Health 1;6(3):e005604
[iii] See for example: Zoomers A, 2010. Globalisation and the Foreignisation of Space: Seven Processes Driving the Current Global Land Grab. Journal of Peasant Studies 37 (2): 429–447 and Borras SM, Mills EN, Seufert P et al, 2020. Transnational Land Investment Web: Land Grabs, TNCs, and the Challenge of Global Governance. Globalizations 17 (4): 608–628.
[iv] The digital world, with vast amounts of wealth embedded in big data sets about individual preferences and behaviours, has been particularly vulnerable to colonisation and extractive rent-seeking. Individuals themselves have become commodities to be captured, manipulated and sold in what has been called ‘surveillance capitalism’.
[v] Cox RW: Civil society at the turn of the millennium: prospects for an alternative world order. Review of International Studies 1999, 25:3-28.
[vi] The history of the emergence of a neoliberal school of thinking that opposed post-war redistribution, the welfare state and Keynesianism as well as its subsequent widespread adoption and deployment globally by certain national governments (the United States and United Kingdom in particular) and the Bretton Woods Institutions is well described in: Harvey D, 2005. A brief history of neoliberalism. Oxford: Oxford University Press.
[vii] See for example: Bishop M and Green M, 2008. Philanthrocapitalism: How the Rich Can Save the World.
New York: Bloomsbury Publishing USA.
[viii] Schedler (1997) lists four types of anti-politics: i) an ‘instrumental anti-politics’ whereby political decisions are made by technocratic experts, often based on cost-benefit analyses that are projected as being rational and neutral; ii) an ‘amoral anti-politics’ in which the public domain is privatised, and people reduced to rational, utility-maximizing economic human beings whose interests and preferences are expressed through and derived from the market; iii) a ‘moral anti-politics’ which acts by reifying certain ‘normative positions’ and stifling democratic or political debate through the labelling of any contrarian positions as being unethical, immoral, unpatriotic, or even treasonous; and iv) an ‘aesthetic anti-politics’ which works by undermining educative, informative and deliberative communication and debate, through the trivialising use of simplistic imagery, homilies, and symbolism.
[ix] See for example: Tognini G, 2021. Meet The 40 New Billionaires Who Got Rich Fighting Covid-19 and Marriott A and Maitland A, 2021. The Great Vaccine Robbery. Oxfam America.
[x] See for example: Marriot A, 2023. Sick Development: How rich-country government and World Bank funding to for-profit private hospitals causes harm, and why it should be stopped. Oxford: Oxfam International and Marathe S and Shukla A, 2023. Supporting patients or profits? Analysing Engagement of German Developmental Agencies in the Indian Private Healthcare Sector. Pune: SATHI
[xi] See for example: Madianou M, 2019 Technocolonialism: Digital innovation and data practices in the humanitarian response to refugee crises. Soc Media Soc; 5(3):205630511986314 and Federspiel F, Mitchell R, Asokan A et al, 2023. Threats by artificial intelligence to human health and human existence. BMJ Global Health 2023;8:e010435.
