Charnele Nunes discusses decolonising global health and intersecting axes of inequality in international aid and investment, leadership and knowledge exchange.

This is the sixth blog in the 12 Days of Global Health series.

It is that time of year again (and what a year it has been!). The weather is a bit colder and we start to wind down and reflect on the year that has just passed. The well-known song, “Do they know it’s Christmas?” (1984), starts to make its way on to the radio (or Spotify). The song, made popular in the 1980s as a response to famine in Ethiopia, was the product of pop stars coming together as Band Aid to “save Africa”. Notwithstanding, the question “do they know it’s Christmas?” remains patronising, self-righteous and reinforces negative stereotypes of Africans. The lyrics have since been updated in 2014 in response to the Ebola crisis in West Africa. In the new version, the lyrics have merely been modified to “Can they know it’s Christmas time at all?” which continues to paint an abject image of the African continent and reinforces the division between “us” and “them”. This year I started to reflect and ask myself, in what ways has the global health community replicated this mantra and reinforced division within its own ecosystem?

2020 has been a challenging year for global health. The COVID pandemic halted global economies and has really prompted us to reflect on the current state of the world, population health and the governance of health systems. However, this year has also marked one year in my time serving as Assistant to the Global Health Initiative (GHI). It has been an honour working with our Steering Committee and other affiliated members to support the GHI and organise our various events and knowledge exchange activities. Working with so many different people from the global health community has given me the opportunity to critically reflect on various global health issues from an interdisciplinary perspective. In my opinion, the biggest development this year has been the increased in calls to decolonise global health. Though calls for a paradigm shift in global health have been existed for some time, they have moved to the centre stage in past years. Decolonising global health calls for a re-evaluation of existing power structures in global health, particularly between the so-called global North and South, and questions the histories of colonialism which continue to underpin global health. These result in structural, racial, gender and ethnic inequalities within and between communities globally.

How does coloniality manifest itself in global health?

Investments in global health often represent complex power relationships between the donor and recipient country. Though donors may support or fund social or health programmes in many recipient countries, this may also result in donors having a bigger influence on agenda setting. A 2019 World Health Organisation (WHO) report on global health spending and financial trends in low- and middle-income countries (LMICs) indicated that 26 LMICs rely on donor funding for more than one fifth of their health spending. Such a dependency highlights the most pervasive colonial power structure: economic dependency. Economic dependency can encourage recipient countries to align with the values and politics of donors. This was most apparent with Trump’s Global Gag rule that banned health providers from supporting access to safe abortion care by restricting access to USAID funding.

Leaders in global health are also disproportionately from institutions or organisations based in high-income countries (HICs), and more specifically, they are white elite men. Global Health 50/50 reported that, of the 200 organisations they assessed according to the Gender and Health index, 85% of global organisations active in health and health policy have headquarters in Europe and North America, with two-thirds headquartered in just three countries: Switzerland, UK and USA. Furthermore, 73% of executive heads were men. These statistics highlight a major problem in global health governance: power asymmetries that undermine racial and gender equality. Shouldn’t global health leadership be representative of the populations it serves? Within the global health community, there are moves to ensure that underrepresented people and communities are present in decision making, and more specifically, to advocate for women to be included in global health leadership. A good example is Women in Global Health, an organisation that strives to achieve gender equality in global health leadership by advocating for institutional change and accountability from existing global health leaders. The bid to achieve diversity should also not result in tokenism, where women or ethnic minorities are invited to panel discussions, meetings or included in funding applications simply to meet or fill diversity quotas. Rather, diversity in leadership should be driven by allyship and values that challenge the current status quo.

The bid to achieve diversity should also not result in tokenism, where women or ethnic minorities are invited to panel discussions, meetings or included in funding applications simply to meet or fill diversity quotas

Lastly, research structures and knowledge exchange are too often unidirectional (from North to South) and result in an inequality of opportunity. This is a product of having disproportionate representation of researchers and global health leaders based in HICs, which results in conferences and meetings mainly held in HICs. Additional barriers to scholars from the global South being included in professional development opportunities includes visa implications (not being granted a visa to enter the country) or high conference registration costs. The lack of truly representative and inclusive knowledge exchange results in an asymmetry of authorship. Exacerbating this are the barriers that researchers face in getting their research published, such as exorbitant publication costs (it seems a bit costly to pay €9,500 per article as an open access publication fee, right?). Such practices reinforce elitism and exclude underrepresented groups and researchers.

This year, many journals and blogs also reflected on the current state of global health. Some of my favourite pieces, both a mixture of peer reviewed journal articles and blogs, included “What is considered as global health scholarship”, “Decolonising global health: if not now, when?”, “How (not) to write about global health”, and “Will global health survive its own decolonisation?”. The authors discuss fundamental flaws in global health scholarship and provide suggestions on how to combat existing axes of inequality. Reading these pieces, I was both disappointed that global health scholarship is not so “global” after all, but also optimistic for the growing number of voices speaking out against what has been the status quo in past decades. The decolonise global health movement is a call to all leaders and researchers to reflect on their positionality and to challenge existing hierarchies of power. As a global health community, we must do more than simply acknowledge that there is a problem. It’s time to rip off the band-aid and work towards a more equitable future.

The views expressed in this post are those of the author(s) and in no way reflect those of the Global Health at LSE Blog or the London School of Economics and Political Science.

Photo: UN Women launches new global monitoring report on SDGs. Credit: UN Women/Ryan Brown. Licensed under creative commons (CC BY-NC-ND 2.0).