From Dependency to Decolonization in Global Health

COVID-19 is reminding us that global health has long operated a model in which Africans are treated as subjects of a quasi-philanthropic complex that, in turn, feeds one of the largest industries in the world.

Written by Paula Akugizibwe

Aug 14, 2020

A COVID-19 testing site in Madagascar. WORLD BANK/ HENITSOA RAFALIA

Amid the cacophony of ‘wake-up calls’ triggered by COVID-19, the colonial dynamics of global health have particularly struck a nerve on the African continent. These concerns are not new, simply underscored in acute ways that make them difficult to deny or ignore. The pandemic is reminding us that global health—which originated in the colonial-era field of ‘tropical medicine’—has long operated a model in which Africans are treated as subjects of a quasi-philanthropic complex that, in turn, feeds one of the largest industries in the world.

This model is increasingly subject to a swell of critical scrutiny from within the field. At the global level, American and European institutions have ironically—but not surprisingly—occupied a prominent space in that critique. Over the past year, several universities including Harvard, Duke, Edinburgh, Johns Hopkins and Sweden’s Karolinska Institute have organized conferences under the banner of decolonizing global health, more recently collaborating with African institutions such as the University of Pretoria’s Journal of Decolonizing Disciplines and the University of Rwanda.

At the heart of these conversations are what the Duke Decolonizing Global Health working group described earlier this year as ‘frustrations with how global health continues to be taught and practiced in depoliticized, ahistorical, and uncritical ways’. Arguing that the progressive framework of global health equity—which has gained popularity in recent years due to its emphasis on the socio-economic drivers of health disparities—is not enough, they instead proposed a more radical engagement with ‘larger structures of oppression and our collective roles in upholding […] the organizational apparatus of the current globalized world order’. This, in turn, demands rigorous political engagement at every level, from the intimate to the macro-economic. ‘You can’t talk about decolonization if you’re not going to name the root causes of oppression’, says Tlaleng Mofokeng, a South African medical doctor who recently became the first African woman to be appointed as United Nations Special Rapporteur on the right to health. ‘Oppressive systems such as racism, sexism, capitalism […] the point is not to just make them less violent, because it’s impossible. You have to actually end them.’

While this imperative lies at the heart of decolonizing healthcare, says Mofokeng, it is undercut by the fact that many benefit from oppressive systems—and health is not exempt from this. Medicine, she points out, has always been used as a political tool, and needs to be examined through the lens of the broader socio-economic realities in which it is deployed. The reliance of African health systems on foreign aid is one of those realities. ‘It’s shocking,’ she says, ‘the philanthropy-cation of healthcare.’

In May, The Lancet, one of the most influential medical journals in the world, added its voice to calls for decolonization in an editorial that urged global health actors to ‘reflect on practices that have their origins in nineteenth-century imperialism and replace them with new systems that are rooted in values of recognition, reciprocity, and respect.’ But while criticizing asymmetrical power structures, the editorial inadvertently illustrated them through its preoccupation with ‘the dangers of the poorest countries being left in the dark’, which were laid out alongside appeals for more resources from the international community. Even calls for decolonization struggle to escape the shadow of one of the most intractable colonial hangovers: economic co-dependency.

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Paula Akugizibwe

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