The Ouroboros of global health: October edition of the Decolonising Global Health blog series

About the authors:

Sarah Alkandari is DPhil student at the University of Oxford studying Translational Health Sciences.

Sridhar Venkatapuram is an Associate Professor in Global Health and Philosophy at King’s College London.

Global health has spent more than a century rebranding itself. Each new iteration promises a clean break from the past, yet it still retains an implicit logic that health is ‘done by us, for them’. The problem isn’t that the name keeps changing – it's  that it has always pointed outward, toward somewhere else, somewhere in need of saving, studying or fixing. We’ve accepted each reincarnation as progress. But what looks like evolution is really the endurance and persistence of a system that survives by renaming itself.

The Ouroboros

What we now refer to as ‘global health’ has been re-incarnated many times. Just like the mythical snake the Ouroboros (tail-devourer in Greek) which is continually reborn from itself,  global health consumed each previous version of itself. The problem with the constant rebranding is that new iterations have the same uncomfortable issues as their predecessors, its history keeps being pushed down, as the underlying logic remains the same.

Ouroboros illustration, from Parisinus Graecus 2327, an alchemical manuscript copied by Theodoros Pelecanos in 1478 (Bibliothèque nationale de France).

Global health started as tropical medicine in the late nineteenth century, a field born out of colonial necessity.  After the Second World War, international health replaced tropical medicine as a softer language of cooperation. When the European colonies were dismantled in the 1960s, the global population was re-shuffled into the First (capitalist and industrialised), Second (communist) and Third Worlds (everyone else). While Third World is now recognised as pejorative, the hierarchical assumptions behind it are still there in the words we use today.

In the late 20th century, development became the dominant framing. While it may seem neutral, it is far from it. It implies a linear path towards a Western model of social progress and is a binary division of the haves and have nots, echoing old-world civilised versus uncivilised division.

Economic descriptors (high/middle/low income, resource rich/poor, etc) which have been developed by the Word Bank and adopted by global health organisations are similarly problematic. They attempt to capture economic status rather than social development, and rank countries by their economic context. These terms focus on deficiencies and deflect attention from the systemic causes that create such limitations (structural inequality, colonial legacies, exploitative global policies, etc). The same applies to the Global North and the Global South. They’re a better attempt at capturing the historical, political and economic inequities of countries, but they homogenise diverse countries, reinforce binary thinking, obscure local differences and the domination of G8 (North) countries.

Finally, we come to ‘global health’. The word ‘global’ implies universality, but in practice it draws a boundary across the globe. When many of us say global health, we mean obesity in Nauru, maternal mortality in Bangladesh or vaccine delivery in Sierra Leone. We rarely mean obesity in the United States, maternal mortality in the United Kingdom or vaccine delivery in Japan.

Letting the Ouroboros rest

All these names are just iterations of the same system - one that operates with an implicit logic that knowledge, funding and authority flow from one small group to the rest of the world. This asymmetry is what sustains global health as a discipline. It relies on distance - between donor and recipient, expert and subject, saviour and victim, here and there.

Suggesting alternative language might seem like a band-aid and another round of tokenistic repair on a system that will always resist deeper reform. That is true. But language also offers a place for resistance to begin. The growing use of the term ‘decolonisation’ by academics and policymakers in the West is an example of the impact of lingual resistance begun from those in the South. The shifts we see today - the growing willingness confront the politics of expertise and decolonise academic curricula - were once dismissed as radical or uncomfortable. Now, they’re part of mainstream discourse.

The guide pictured below offers one way to begin, not a solution. Semantic language tweaks won’t dismantle systemic power hierarchies, but they can expose it. Small shifts in how we speak can loosen soil around deeply rooted colonial systems.  The Ouroboros will always renew itself – but perhaps in the future, global health can emerge from that renewal less self-consuming, more self-aware and oriented toward genuine reciprocity.