On the Pervasiveness of Self-Interest and Careerism in Global Health— and How Greater Literacy in Ethics & Ethical Reasoning Might Help
Note: Continuing the Miami Institute forum on “What does it mean to decolonize global public health?,” Sridhar Venkatapuram adds to David McCoy’s essay, “An Anti-Colonial Agenda for the Decolonisation of Global Health” (October 2023) by stressing “the need to address careerism/self-interest in global health and second, the usefulness of ethics and ethical reasoning in decolonizing global public health.” In a few weeks, essay contributors to this forum on decolonizing global health will gather virtually at the Miami Institute for a closing, public discussion of their essays. Please stay tuned for the date of this live conversation.
I agree with much of David McCoy’s target essay in this discussion. It is both accessible and insightful, and especially valuable for not just describing the problems of injustice in our present global health world but also providing points of action. In this response, I summarize what I understand to be core points of David’s essay and suggest one minor tweak. Then I aim to add to the discussion by raising two points. These include the need to address careerism/self-interest in global health and second, the usefulness of ethics and ethical reasoning in decolonizing global public health.
David’s argument is that present day colonialism and “colonialist like” efforts have to be recognized as also happening in new trans-national spaces that are not tied to particular geographies (i.e. colonies) and occurring through new forms such as financialization and digitalization. The word also is important here because old forms are still continuing while new forms of domination and extraction of resources, both old and new (e.g. human data) have emerged, for the material and social benefit of the few. These few beneficiaries are not just imperialist nation-states, but also global monopolistic corporations, as well as the few super-wealthy billionaires, some soon to be trillionaires. Against this persistence of old (as well as the rise of new) forms of colonialism in general, David argues for decolonizing global health in three ways:
First, to resist the macro and micro forms of colonialism in the day-to-day practice of global health. This includes decolonizing everything from teaching and training, research, evaluation, programme delivery, funding, and so forth.
Second, to challenge the dominance of certain actors in global health whether they be nation-states or funders who have influence by virtue of the “pay-to-play” ethos of global health institutions.
Third, to challenge the shaping and use of global health efforts for resource/profit extraction, again for the benefit of the few.
As David is implicitly pointing out in the essay, decolonising global health as rhetoric and a coalescing movement does not offer established core tenets such that they can be easily applied to global health. He is offering both an analysis and agenda. Indeed, decolonial thought, thinkers, and related academic studies have been around since the early 20th Century. And such thought was visible in the Alma Ata Declaration and many other UN and other post-colonial efforts of that time. But indeed, our present decolonizing global health movement is relatively new. It is new because “global health” as a term (or rebranding of international health) is new as well as the unprecedented increase in scale since 2000 of funding to health development assistance, organizations, research, teaching, and related activities. Decolonizing global health advocates are aiming most directly at this post-2000 phenomenon.
One tweak I would suggest is that while David writes that decolonise global health efforts began three or so years ago, I see its origins in the South African student and staff protests that began in 2015 with the Rhodes Must Fall campaign. They began with the aim of addressing institutional racism at the University of Cape Town, and then expanded scope to decolonising all education in South Africa. The tangible decolonizing actions of taking down statutes and plaques that celebrate racists, imperialists, slavers, colonisers, and others of such ilk began in Cape Town. South African students also inspired their fellow students at universities across the world, particularly in the United Kingdom and United States. African students at Oxford, some of whom were training in global health, wanted the local Rhodes statue to also fall (Rhodes Building). And such focus on statues spread to other universities and places such as Bristol during the BLM protests, taking place during Covid lockdowns. During 2017-19, I was approached a few times to participate in or organize decolonizing global health conferences and events, which I declined. I will explain my reasons further below. More presently, I would like to add to David’s argument.
Because David uses colonialism as the main framework to analyse the many problems in present-day global health, it motivates me to ask, does colonialism explain fully the breadth of problems, and does and will decolonizing global health fully mitigate all or many of the biggest problems? I would argue that if decolonizing global health is to be meaningful, we need to address head-on the issue of the pernicious and pervasive self-interest and careerism in global health.
As I mentioned above, I declined invitations to contribute to decolonizing global health events because the motivations were not clearly to greatly dismantle colonialism in global health, but to be the first-movers in rich country academia on the topic. These events were very unlikely to have a decolonizing impact especially when organized at the most elite public health institutions in the US and UK. These institutions are greatly invested in holding onto and expanding their global health portfolios. Part of decolonizing global health must mean that many people, including well-meaning global health students, have to relinquish their power and advantages, and importantly, forgo opportunities for gains of various kinds. Those being dominated, excluded, or silenced by old and new forms colonialism have to be in the lead. Without such a transformation, David’s three-point agenda for action will be usurped by individuals who will find ways to interpret and transform the agenda into gains for themselves and their employers. Let me explain.
One reason I am so focused on self-interest and careerism in global health is that I have seen first-hand the difference between addressing the structural political economy of health (social injustice), which involves speaking truth to power and bearing the costs, versus careerism. I was witness to the moment when HIV/AIDS activism died, and professionalisation began. When large amounts of money poured into HIV/AIDS efforts, such as in India in the late 1990s, activists who sought to change the social conditions and empower individuals to have control over their bodies and behaviours were soon overwhelmed by a new group of public health and funding/programme manager experts. These experts did not see themselves as part of affected communities but as expert-helpers and saviours of those communities. This difference between helping ourselves versus helping them showed in the programme decisions made by the new professionals—the decisions had to be good for their own careers, then good for their employers, and lastly, good for the communities affected. All the while, the work would not be upsetting to those in power. What results is superficial gains in health that can quickly be reversed or erased.
David is right in pointing out that self-interested actors and agendas should be resisted in global health. But (!!), we need to make it more explicitly clear that resistance will have costs, and individuals must be willing to bear those costs in terms of their own future careers and wellbeing. As I have come to recently appreciate after a decade or more in academia, there are no inert institutions. There are people who make up and hold up institutions. And, for decolonization to occur, people inside global health and other organizations will have to be willing to pursue needed actions for the sake of freedom for others, for ourselves. Because that is what is stake in decolonization. The opposite of domination, exploitation, and resource extraction is freedoms for individuals and communities. Without a link to the psychological mindset of anti-colonial freedom-fighters, it would seem that we are seeking the professionalization of anti-colonial resistance. This is not going to go very far.
This brings me to the usefulness of ethics, and ethical reasoning. One of the reasons I chose to train in philosophy, particularly political philosophy, was in light of the difficulty and errors we make in arguing for what the world should be like based on the understanding of what the world is now. This is what philosophers refer to when they talk of the is-ought problem. The possibilities of what the world could be like are far more expansive that what we see in the world presently. To take a simple example, in seeing that people are dying from the lack of access to insulin, it seems natural to say that such people should have access to insulin, or that they should have a human right to insulin. While the intuitions are right, such reasoning can be easily critiqued or dismissed. Some might respond to such rights talk by saying that there are so many different causes of people dying, and using the language of human rights is just empty rhetoric or emotional language to press the needs of one special interest group. Ethics and ethical reasoning can help us be better thinkers, advocates, and activists by freeing up our imagination about possibilities of a better world.
Decolonizing global health as well as motivating individuals to become anti-colonials will require much clearer thinking about the ends and means. In thinking both about what is wrong now and what should be in global health, we need to think more clearly and also be able to explain to others, most of whom don’t see global health as profoundly troubled. In fact, many people in global health are doing quite well, want to keep progressing in their careers, and will resist losing their hold as if their lives depended on it.
The illiteracy in ethics and ethical reasoning, particularly in global health, has allowed so many bad things to happen under the cover that everyone and everything in global health is pursuing the unassailable and virtuous aim of preventing death and disease of people, particularly in resource-poor countries. While colonial analysis and a decolonizing global health action plan may be accurate, we need to directly address and supplant the pervasive self interest as well as help people be more skilled in providing reasons for what we are seeking to achieve, and for the ways we seek to achieve things. The risk is clear and too great that decolonizing global health will also become co-opted and become just another cover for bad things happening.
-Sridhar Venkatapuram
Sridhar Venkatapuram is Senior Lecturer (Associate Professor) in Global Health and Philosophy. He is based at the King’s Global Health Institute where he is Deputy Director, and Director of Global Health Education and Training. Sridhar conducts impact driven interdisciplinary research that aims to improve understanding and realization of health equity and justice. He is known for helping establish the area of ‘health justice’ philosophy, for engaging with and advising public/global health practitioners, and for amplifying ethical reasoning in public/global health education, research, and practice. He has been at the forefront of public/global health ethics for over 25 years starting in the early 1990s as the first researcher at Human Rights Watch to focus directly on health-related human rights violations (HIV/AIDS in India). He has won numerous awards, grants, and fellowships including Wellcome Trust Research and Senior Research Fellowships. He has been elected to prestigious professional organizations, commissions, and panels including the RSA, Faculty of Public Health, Human Development and Capability Association, and Lancet-Univ. of Oslo Panel on Global Governance for Health.
Sridhar has worked with or advised diverse organizations such as Population Council, Soros Foundations, Doctors of the World, Minorities Rights Group International, Health Foundation, and the World Health Organization (HQ, MENA). His academic training is in a range of disciplines, including International Relations (Brown University), History (SOAS), Public Health (Harvard University), Sociology (Cambridge University) and Political Philosophy (Cambridge University). His doctoral dissertation on the philosophical argument for a moral/human right to 'the capability to be healthy' was examined and passed without corrections by Amartya Sen, Nobel laureate, economist and philosopher. It formed the basis of his first book, Health Justice: An argument from the capabilities approach (Polity Press). His latest book is a co-edited collection of scholarship on the philosophy of public health.
