Embrace the discomfort to catalyse change: July edition of the Decolonising Global Health blog series
In the July edition of our 12-part Decolonising Global Health blog series, MSc in Translational Health Sciences alumna and incoming DPhil candidate Sarah Alkandari is joined by guest author Dr Sridhar Venkatapuram to explore why talking about decolonising global health can feel uncomfortable – and why that discomfort matters. Together, they examine the colonial roots of the field, the challenges of meaningful change and whether the field can be changed from within, or if real progress means starting from a new foundation.
About the authors
Sarah Alkandari is a strategy specialist who conducts research on health research innovation, policy and capacity building in Kuwait. She works at the intersection of theory, evidence and strategy. Sarah is an alumna of the MSc in Translational Health Sciences at the University of Oxford and will start a DPhil in the same field later this year.
Sridhar Venkatapuram is an Associate Professor in Global Health and Philosophy at King’s College London. He is an interdisciplinary scholar, blending ‘health justice’ philosophy, public health and human rights to shape health equity and justice in the field of global health.
The call to decolonise global health is inherently uncomfortable for those of us living in former coloniser societies. The phrase provokes shame and guilt. It provides no easy and clear solutions; but mostly, discomfort is due to our repressed intuitions that the very construct of global health is fundamentally flawed.
Global Health is a colonial project
There is no consensus on the definition of global health. However, global health being an 'an area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide' may be an easy starting point. Nevertheless, this sentence can’t outrun the echoes of its ancestral origins. As Xiaoxiao Kwete puts it: 'global health is old wine in a new bottle.' In all its forms, global health still operates along the old colonial dynamic where the ‘global North’ is acting on the ‘global South’. In retrospect, the duplicity of colonial rhetoric-claims that actions were taken for the benefit of the colonised-is now evident. Until very recently, it was nearly impossible to challenge duplicity and contradictions within global health, especially while the field was booming.
The links between global health and colonising are there for those who want to see them. Starting in the 15th century, when Europeans began imperial and colonial expansion across the world, a speciality in medicine was born to protect European colonisers (in all their forms) from disease and death during the voyages and on arrival in distant lands. By the late 19th century, academics in Europe were contributing to something called tropical medicine. After the Second World War and the dismantling of European empires, new post-colonial dynamics emerged in the form of special development aid relationships between former colonisers and their former colonies. This led to the rebranding of tropical medicine as international health, reflecting the increasing number of newly independent nation-states that continued to face many of the same health challenges experienced under colonial rule. The 1990s saw the evolution of international health into global health. This new label recognised the role of non-state actors, international institutions and processes at the global level, addressing the health impacts of globalisation within and across countries.
Global health has rapidly grown since the new millennium, yet a new movement to decolonise global health has also been gaining traction. Partly in recognition of the duplicity in the rhetoric of global health, the momentum is growing in response to the now visibly persistent neo-colonialist dynamics. In particular, that of resource extraction (data, labour, profits, social rewards, etc.) that shows no sign of ending.
A notable catalyst of the movement was the 2015 Rhodes Must Fall student protests in South Africa. The activists did not just want the coloniser and racist Cecil Rhodes’s statue overlooking the University of Cape Town toppled. Their main aim was the decolonisation of the whole university curriculum and access to education. They wanted the entire project of what and how to think, and who gets to think stripped of its former colonisers’ pernicious influences. This movement spread across countries, including the Rhodes Must Fall campaign at the University of Oxford. Perhaps because the issues resonated so loudly in global health, students established the first academic Decolonising Global Health Working Group at Duke University in 2018. Since then, six student-led international conferences on decolonising global health have taken place (three in the United States and three in Europe). While this shows momentum, ironically, it also shows the dominance of ex-colonial powers in the movement-at least in academia. Decolonisation is a phrase that has become familiar to many in global health. Yet, the movement itself remains at the level of rhetoric rather than producing a platform of practical, meaningful structural changes.
The issues with decolonising
It’s tokenistic
The attempts to decolonise global health is not helped by its broad and intimidating intent. Tuck and Yang caution that 'decolonisation is not a metaphor' and that its facile adoption by academic and international aid organisations can be tokenistic. Superficiality not only dilutes the fundamental intent of decolonisation but replicates the colonial logics it seeks to dismantle. Nayantara Sheoran Appleton refers to this as 'academic rebranding'; manifested through futile training courses, workshops and conferences that many of us have come to know well. Meanwhile, Castor and Borrell describe an 'epistemological-praxis dissonance' that arises from the disappointment when positive expectations (achieving something towards decolonisation) clash with negative experiences (ineffective decolonisation). They suggest that to reduce psychological dissonance, people will reduce their behavioural output through a lack of ownership and engagement. In essence, people give up because it’s hard.
Understandably, the call to decolonise global health is intimidating. The word itself places blame on all involved in global health participants as being colonisers. It relies on the emotive ‘sins of the West’, which in turn stigmatises an entire racial group for the misdeeds of their ancestors. It also elicits misplaced guilt. As Bruckner puts it in his book The Tyranny of Guilt: An Essay on Western Masochism, Western academics are faced with 'endlessly atoning.' Regardless, it’s too simplistic and reductionist to assume that the Western malaise stems only from the links between past colonialism and global health.
There is an inherent paradox in attempting to decolonise a system that is, by its very nature, colonial. The movement of decolonising global health is militating against the fact that global health now reflects the continuing hierarchy of humanity established largely through European and indeed, other agents of colonisation. Global health sits behind a veneer of benevolent rhetoric of saving lives. But it fails to address the structural causes of persistent ill-health and health inequities within and across countries, fails to allow former colony countries to become self-sufficient, and ‘others’ the world’s majority population of the global South by reducing them into passive objects. Global health's architecture inherently relies on and further replicates colonial hierarchies through persistent power asymmetries, epistemic colonialism and economic exploitation and extraction. This creates a self-perpetuating cycle, where efforts to ‘reform’ colonial structures inadvertently reinforce them by demanding conformity to Western frameworks, as if they are the only ones available.
Abandon or rebuild?
If decolonisation requires dismantling colonial structures and epistemologies, then clinging to global health as a concept may be the biggest obstacle of all. The fundamental problem is not how to decolonise global health, but that the concept of global health itself is irredeemable. The phrase 'global health' assumes a universal standard of health (defined by whom?), a neutral, technical framework (despite it emerging from colonial medicine), and that health can be separated from power (when it has always been political). Ultimately, there is no real ‘global’ in global health, only a sublimation and replication of colonial hierarchies under a 21st century rebranding.
The discomfort is the point
Talk of decolonisation should be uncomfortable, and the jarringness of the word should not be manipulated out to placate the discomfort it creates. As Farchanda Abdoeil Wahid puts it: 'We know that the decolonisation discussions make the Global North uncomfortable, but lest they know, we have been uncomfortable for as long as we can remember. Endure the discomfort, in this way, perhaps they might learn something'. What we are beginning to learn is what we sort of already knew: coloniality is not a bug in global health, it’s the whole operating system.