A recent article in BMJ Global Health calls attention to the way that existing global health efforts and models are insufficient to address structural oppression. A team of graduate student researchers in the U.S. argue that responses to the COVID-19 pandemic have accentuated these shortcomings, providing insight into new avenues for transformation.
In their paper, the research team calls for a three-fold shift in paradigm, leadership, and knowledge to decolonize global health:
“As early career global health practitioners, we see this pandemic as an opportunity to critically appraise what is not working and to offer an alternative vision for the future of global health. 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 COVID-19 pandemic has highlighted the structural violence that occurs within countries and between them. Structural violence refers to discriminatory and oppressive practices that are legitimized and perpetuated through laws, policies, and norms. The authors draw upon this definition of structural violence to demonstrate that marginalized communities are “ignored and exploited by design” and thus, the disproportionate and negative health impacts of COVID-19 on these communities can be understood through this lens.
Influencing the design of global health approaches are global histories of redlining, slavery, environmental racism, and predatory capitalism, the authors write. Importantly, individuals who are marginalized and disadvantaged by these structural inequities make up the global majority. Therefore, structural violence may be considered a determinant of health to which global health responses have failed to address.
The team describes the risks associated with a global health approach that does not meaningfully consider structural violence:
“This reality shows that the current global health ecosystem is ill-equipped to address structural violence as a determinant of health, and the system itself upholds the supremacy of the white savior… Without acknowledging these oppressive forces, the pandemic response will lack context-specific and targeted policies to address the structural racism that enforces these health disparities.”
The authors draw upon examples of the direct impacts on marginalized communities, describing the effects of the novel coronavirus on Indigenous communities in the U.S. and migrant workers in Singapore. These effects must not be divorced from violent histories of dispossession and destruction, argue the authors. Poor access to healthcare in the pandemic and the devaluation and failure to protect workers are thus linked to legacies of colonialism and power imbalances that have historically imbued social hierarchies. The authors cite research to note that in many settler-colonial states, Black and Brown people comprise a major portion of the essential workforce.
However, global health not only falls short when considering the direct health effects on individuals in marginalized communities but in colonialist patterns that have centered Westernized knowledge systems. The authors make the argument that responses to the pandemic have been shaped out of these Western knowledge systems. Racist language (e.g., “Chinese virus”) and responses (e.g., scapegoating practices that harm East Asian populations) demonstrate some examples.
When global health practices are determined by institutions in the “Global North”, there tends to be a lack of representation which results in practices ill-fitted to the needs of many as well as adverse health outcomes. High-income countries are often driving the global health discourse at others’ expense:
“The notion of simply ‘copy-pasting’ strategies like lockdowns and social distancing measures does not work in spaces like cramped migrant worker dormitories, refugee camps, urban slums, or anywhere else the poorest and most marginalized are forced to reside. How can a family of 15 go into lockdown in a slum complex that houses 700 000 others? How can you practice good hygiene such as handwashing when the water itself can be a scarce commodity? When the people in power represent only those with social dominance, the health needs of the marginalized majority inevitably get overlooked.”
In response to shortcomings in global health, this team of researchers aligns with the student-led movement to decolonize global health. They call for re-politicizing and re-historicizing global health research, policy, and practice to more deeply engage with local and global structures of inequity.
Therefore, the researchers summarize a three-fold agenda to decolonize global health:
- A shift in paradigm. By re-politicizing global health to be grounded in social justice, the impact of the “isms” (e.g., colonialism, racism, capitalism, sexism, ableism) must be viewed as interlocking with health. They write, “A paradigm shift involves individuals and institutions acknowledging that disease cannot be extracted or isolated from broader systems of coloniality.” Global health missions, programs, and structures must be adapted to account for these determinants of health.
- A shift in leadership. A shift in leadership involves equitable representation across spheres of research and agenda-setting in global health. Currently, underrepresented voices, such as those of individuals in the “Global South” and women ought to be recognized and elevated.
- A shift in knowledge. The researchers offer suggestions to move away from unidirectional knowledge flow to a reciprocal one in which students are taught to apply critical inquiry and examine the racist and colonial histories that have engendered inequitable disease burdens. Furthermore, in recognizing that most global health resources and training programs are offered in the English language, the authors suggest attending to geopolitical imbalances to create new learning platforms for global health.
This three-fold shift represents a robust effort toward global health transformation. At the heart of this mission is the argument that individual health must be understood within structural and historical contexts that allows for the redress of power imbalances. The authors clarify that “Fundamentally, this shift means changing who sits at the table and rebuilding parts of the table itself.”
Furthermore, the research team makes the case that amid the context of the global pandemic, it is time to realize this opportunity for transformation:
“While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health. A student-led decolonizing movement is one step. Now, the movement must expand in numbers and scope to create a more just and equitable future.”