Global inequities intensify debate on decolonizing health care

COVID-19 has amplified the issues of social justice and health inequalities caused by imbalanced power structures and has compelled institutions and their leaders to confirm a commitment to diversity and inclusion and disavow racism.

Global health structures, such as the World Health Organization and World Bank, have reaffirmed their commitments to diversity, inclusion, and equity. Places of higher learning in high-income countries (HICs) have committed to the same, thereby intensifying the call to decolonize global health that has been urged over the past several years. Thus far, it appears that the debate has been mostly from one side – those who benefited from the exploitation of countries. The need for the active participation of low- and middle-income countries (LMICs) in global health decolonization efforts is being eclipsed.

Tropical medicine provided European colonizers with a justification for racial supremacy and the rationale for subjugation and control of colonized countries. Colonial regimes also practiced tropical medicine to control the movement of native inhabitants while belittling local cultures and eliminating indigenous education systems in favour of Western ones. Subsequently, colonial countries formed global structures that preserved oppression and supremacy through dominance in global health organizations, practices, operations, control, location, agenda-setting and the global knowledge space.

Today, global health refers to “improving health and health-care equity for populations worldwide” and includes sociology, economic disparities, public policy, environmental factors and cultural studies.

Decolonizing global health seeks to dismantle the products of oppression and supremacy that are exhibited in asymmetrical power relationships in research, control of economic resources and global agenda-setting. Beyond these are issues of classism, racism, casteism and patriarchy.

Decolonizing global health is expected to eventually produce increased participation of community representatives (where applicable) and experts with lived experience of health issues, contexts and geographies from LMICs in the governance structures and advisory bodies of global health organizations. Likewise, decolonizing global health education entails the re-examination of assumptions and practices underpinning partnerships between institutions in LMICs that were previously colonized and HICs that were the colonizers.

However, the Global South’s role and involvement in decolonizing global health must be called into question. The challenges remain from the root to the top. While educational curricula in the Global South are being developed to reflect and respond to specific countries’ current and projected needs, programs like global health studies or non-profit and social sector management are low on the agenda. Significantly, the lack of gainful employment opportunities for allied health and related professionals contributes to the brain drain to the Global North.

The question is how this movement will bear fruit when its roots remain deeply entrenched in its colonial past.

My first exposure to the process and implications of colonization in an academic environment came during my undergraduate years in Nigeria through Thomas Pakenham’s book A Scramble for Africa. I read it as the “gospel truth,” influencing my thinking, mindset and outlook. Through this book, I traced what I believed was the genesis of Africa’s many problems. The same undergraduate course made me question Africa’s passivity in her invasion, occupation and division. I questioned how a few people – participants of the Berlin Conference representing 14 countries including Belgium, France, Germany, Netherlands, Portugal, Spain and the United Kingdom – could make such weighty decisions about my country, my continent without her accord. Decisions to “civilize” and pillage.

What the course did not foster was an interrogation into how colonial ideologies have shaped the current reality. Teaching about colonization from a local perspective would shed light on the importance of that historical period in shaping current realities and allow students to investigate relevant questions.

Today, I question how future occurrences are being guarded against now that Africans know that exploitation led to underdevelopment.

The question is how this movement will bear fruit when its roots remain deeply entrenched in its colonial past.

Reflecting on my educational experience in Nigeria, and that of other undergraduates at the time, I am inclined to conclude that the pedagogical approach does not generally encourage or promote student interest in research, policy and practice.

Young minds are not always included in capacity-building programs such as workshops and seminars and do not have the opportunity to engage in meaningful discussions or debates about national, regional and global developmental issues. Such exposures would provide a sense of contribution and belonging and also shape the ideas of the citizenry toward national and global development.

In addition, plans for developing and retaining a workforce with the skills required for high productivity and career advancement are not taken seriously in Africa. Graduates with needed social science training and medical degrees are either unemployed or underemployed. A recent Bloomberg report noted that a third of Nigeria’s labour force is unemployed or under-employed, forcing many to emigrate. This move abroad is robbing many countries of its most brilliant researchers. Talent that was once stripped from the African continent via ships is now leaving on airplanes.

There has been little commitment from leaders in LMICs to fill the space a decolonized global health will leave and current curricula do not pay sufficient attention to the decolonization of health in its entirety. The conversation must actively include LMICs and seek to redress power imbalances; prevalent tribalism; improve governance of physical, human, and economic resources; and displace the patriarchy within and between country boundaries.

However, there is concern about the meaningful engagement of countries in the Global South. Talent and skills are needed to create decolonized global health but the conversation on decolonizing global health education is barely a whisper within institutions in LMICs. A search for a Master’s degree in Global Health on the internet leads you to institutions in Australia, Canada, Belgium, France, Germany, Netherlands, Portugal, Spain and the United Kingdom, not the Global South. Health and related disciplines taught across LMICs are founded on the legacy of colonialism, through the lens of HICs. The curriculum for health sciences and adjacent courses is filled with foreign content, such as how symptoms look on non-dark skin. Students are still learning that Mary Slessor stopped the killing of twins. Graduates emerge with an air of class superiority similar to that which medical practitioners during the colonial era possessed.

For decolonization of global health to be truly successful, there is a need for Global South countries to step up and address the legacies of colonialism within their health and education sectors. Such legacies undermine the value of local knowledge and favour foreign solutions. LMICs have not invested sufficiently in research and education institutions that critically train researchers and practitioners for this required shift in orientation.

But where will these local health leaders in LMICs come from? Figures from the African Development Bank’s (AfDB) African Economic Outlook 2020 show that government spending on education in Africa is negatively associated with school enrolment for all levels of education. Health and welfare degree courses account for less than 10 per cent of university enrolment. What is more disheartening is that less than 10 per cent of those 25 years and older have a university education.

And are countries from the Global South ready to form equitable partnerships in decision-making and fulfilling financial obligations on the world stage or are they only interested in receiving foreign aid? Is idealism and altruism from global health practitioners in the Global North enough to foster a truly decolonized global health?

Decolonizing global health involves more than what academic and research institutions in HICs must give up in terms of leadership roles and faculty disparity – there are enormous financial obligations such as funding in-country research institutions.

How can we possibly decolonize global health when our foresight in the Global South is short? Public health, which concentrates on local communities, and not global health is the program of choice available in most African universities. A demand-driven education system focusing on ensuring graduates are job-ready and have access to rewarding careers is a good place to start improving policies and nurture future generations that will stand shoulder to shoulder with their colleagues globally and determine the course of a joint global future.

Demand-driven education will ensure graduates can re-write the development narrative and participate in knowledge-sharing platforms. It will ensure that young minds develop decision-making, technical, advisory and coordinating skills needed at global levels.

With a sizable number of health professionals equipped to address the imbalanced power dynamic in global health, decisions like those that prevent access to life-saving treatments will not be imposed on Global South countries.