Decolonizing Global Health Practices

Beyond its health and economic impacts, COVID-19 has also evidenced social inequalities and serious discriminatory arrangements within and between countries. “While the manifestation of inequity in each country or region is bound up in the local-to-global interface of historical, economic, social and political forces, COVID-19 disproportionately affects the world’s marginalized,” states a report by BMJ Global Health. The report describes how, during the pandemic, social outcomes have been greatly influenced by the level of access that an individual or health system has to the necessary supplies to face and overcome the disease.  “The capacity to prevent infection through non-medical countermeasures, like handwashing and social distancing, as well as economic security while in lockdown, are all mediated by the confluence of global, regional and local systems of oppression.”

The BMJ report states this dynamic shows that the current global health ecosystem is equipped to address structural violence as a determinant of health, while the system itself upholds the supremacy of the white savior. “Global health needs integrated, decolonized approaches — advanced by individuals and institutions— that address the complex interdependence between histories of imperialism with health, economic development, governance and human rights.”

The Origins of Global Health

An article by Unite for Sight explains that European colonization had enormous effects on the health of both indigenous populations and colonists through the transfer of new diseases, mechanisms of oppression and the process of urbanization. Colonialism’s negative impact on public health can be divided in three: the introduction of non-native diseases, the rapid spread of disease and the extraction of wealth that prevented indigenous people from “growing out” of the cycle of poverty and disease.

Laura Mkumba, Co-Founder of the Duke Decolonizing Global Health Working Group, explains that global health was first though out as a way for public health institutions in colonialized countries “to care for the colonial personnel and to keep the local workforce and slaves working efficiently” to extract wealth to benefit colonizing nations. According to Unite for Sight, today’s structures of power left by colonialism continue to exacerbate the already top-heavy distribution of wealth in nations that were once European colonies.

In Mexico, the situation was no different. Preserving the well-being of the New Hispanic population was a recognized need addressed by Spanish authorities, which sought to include the local population in the healthcare system with different degrees of effectiveness, depending on of the head of the viceregal government in turn.

A research paper by Consuelo Córdoba-Flores, from Universidad Autónoma Metropolitana, describes that the good health in indigenous society before the conquest was eclipsed by various epidemics that hit New Spain as a consequence of the arrival of new diseases. These were fueled by new forms of work, mistreatment, misery and malnutrition suffered by the subjugated natives. Faced with the problem of an unhealthy population that represented the bulk of the local workforce, the Spanish government was forced to build hospitals.

Córdoba-Flores’ findings detail that the healthcare and health institutions in Mexico, from the colonial period to Porfirio Díaz’s, were always determined by different public health policies defined by the administration in turn’s particular vision of “good governance.” The transformation of these health systems from “charity” to “beneficence” and eventually becoming a duty of the State, lies more in the exercise of social control, ensuring governability by guaranteeing the health of society. According to Córdoba-Flores, during Díaz’s government and with the intention of maintaining this control is that public health policies regain ideological and legal support in Mexico.

The State of Global Health

There are still major power asymmetries between the commonly called “Global North” and “Global South” in the global health sphere, rooted in economic power imbalances, lopsided global governance structures, racism and colonialism, explains Students for Global Health (SGH). The Global Health 50/50 report found that 85 percent of active global organizations in the healthcare field have headquarters in Europe and North America, with two-thirds in just three countries: Switzerland, UK and US. Low and middle-income countries receive significant aid from global health organizations like the UN or WHO and philanthropic associations like the Bill and Melinda Gates Foundation and Wellcome Trust that, through their funding, hold the power to set health agendas.

The report also highlighted that more than 70 percent of leaders in a sample of 200 global health organizations are men, more than 80 percent are nationals of high-income countries and more than 90 percent were educated in high-income countries. SGH explains that this creates a global health architecture where “powerful men, often older and white, sit in boardrooms in established colonial institutions in the Global North and are responsible for setting the health agendas for countries miles away, with little to no significant involvement with local leaders.”

Abraar Karan, an internal medicine resident at the Hiatt Residency in Global Health Equity of the Brigham and Women's Hospital shared on the NPR how colonialism is still prevalent through medical volunteering when Western doctors travel to unknown territories to help less-educated locals. Karan explains that the relationships within global health are still heavily and falsely dominated by the idea that the Global North is "helping" the Global South. “The opposite is rarely acknowledged or encouraged in any meaningful way. Even when doctors from impoverished countries are brought to wealthy countries as part of exchange programs, it is under the assumption that they are coming to learn from us,” he said.

In Mexico, there is a situation than reflects a similar dynamic. An article written by Xavier Tello, Vice President of Strategy and Commercialization at Byronmuller, states that social service for doctors has been “romantically and falsely conceived as a learning methodology,” through which young graduates approach communities to return to society what they have learned for free, while putting their acquired knowledge into practice. Tello points out that this humanist thesis quickly became a cover for a harsh reality: “the terrible lack of resources to provide the population with first-response medical services with adequate quality.” Medical interns simply became cheap labor to meet the requirement of providing medical care to the most remote populations. It is not a surprise that in rural or indigenous areas, the jungle, mountain ranges or deserts, medical units are only basic clinics, lacking adequate infrastructure and advanced diagnostic elements.

“Under the absurd premise that the mission of the first-contact doctor is to prevent rather than to treat, the obligations of this young intern are not only those of providing the medical care that the limited resources of the practice and their recent training allows them,” said Tello. The intern must supervise drainage works, ventilation of fireplaces, vaccinate dogs and carry out endless administrative paperwork so that his supervisors and the local and regional health authorities follow up on the fulfillment of health goals. “If the intern does not meet set numbers and goals for any reason, he is sanctioned and his social service certificate can be at risk.” Tello’s article also shines a light on the tools that the doctor has on those areas, which are often less than basic. This is an unfair practice for both communities and doctors, as they are both placed in disadvantaged positions, he added.

Decolonizing Global Health

BMJ proposes three key steps to move away from colonial practices and therefore build an equal health agenda, globally:

• Paradigm shift. This involves individuals and institutions acknowledging that disease cannot be extracted or isolated from broader systems of coloniality. Organizations and donors should adapt their missions, programming and structures to account for this reality. Fundamentally, this shift means revising who sits at the decision-making table and rebuilding parts of the table itself to build inclusive environments.
• Leadership shift. A leadership shift would include more equitable representation in academic journals, leadership roles and faculty, reflected, for example, in equitable first authorship positions for collaborators from the “Global South,” as well as women.
• Knowledge shift. This includes teaching students about inequitable global disease burdens while creating an enabling environment for critical inquiry into the racist and colonial histories that gave rise to these disease burdens. This would also bridge geopolitical imbalances in global health education. For example, global health training programs and knowledge resources are mostly offered in English, in high-income countries and at great cost, thus limiting access for people of other languages and from less privileged backgrounds.

An article by The Conversation also suggests global health courses to discourage global health voluntourism, while guiding trainees and graduates on what “they must not do, when they go to low and middle-income countries. How not to save the world must be a critical, required component of all global health courses.”

In Mexico, Tello suggests fair treatment to the professional work that social service doctors are doing by offering the right infrastructure and equipment and the assistance of a trained and experienced local doctor that can teach graduates about the community.