IBADAN, Nigeria – In the wake of George Floyd’s death in June 2020, the decentralized protests initially organized by the Black Lives Matter (BLM) movement triggered an awakening and an echo that has reached well beyond the borders of the United States.

What started as a non-violent movement protesting against incidents of police brutality and racially motivated violence, has also inspired people around the world, including scientists to take a closer look at how colonialist attitudes and structures continue to influence their institutions and career paths. For individuals from comparatively disadvantaged countries, these attitudes often make it difficult or even impossible for them to enjoy equal opportunities and mutually favorable metrics in their chosen careers.

And this is true for global health too. “Little or no attention is being given to the issue. This isn’t something people are funded to look at. Doing it in of itself comes from a position of privilege,” says Dr Mishal Khan, Associate Professor at the London School of Hygiene and Tropical Medicine (LSHTM).

While decolonisation has been discussed in an educational context in the past, in terms of curriculum choices as well as well as the preference of western to indigenious professionals, Khan argues that the fundamental structures underpinning global health should also be closely examined.

“It’s not really researched or taught as much as it should be, and this is why people often don’t think about it so much,” she says, noting that while relics of colonialism remain and debates continue across sectors, the issue has been far less discussed in the context of global health. “The implicit assumption is certain groups are more knowledgeable and better than the others.”

The topic of ‘decolonizing global health’ will be a featured topic on the Geneva Health Forum’s agenda, taking place 16-18 November, where Dr Khan will be a keynote speaker.

“In global health there is an additional element,” Khan adds. “By nature, global health is about higher income countries trying to support low-income countries. It’s not just about teaching global health, but also the practice.”

UN Born With First Decolonialist Wave

According to the United Nations, fewer than 2 million people now live under colonial rule in the 17 remaining non-self-governing territories. out of which only one – Western Sahara – is in Africa.

“The wave of decolonization, which changed the face of the planet, was born with the UN and represents the world body’s first great success,” the UN stated.

The UN’s key global health agencies, such as the UNICEF and the World Health Organization were born in the post-World War II era of 1946-48, in the waning years of colonialism. UNAIDS, on the other hand, came much later, during the worldwide AIDS pandemic, as states in the global south asserted the need for affordable solutions and more recognition of their health challenges. While these international organisations continue to champion and foster partnerships toward achieving global health goals, they are also implicated in these discussions.

In a September 2019 commentary, Richard Horton, editor of The Lancet medical journal said the success of any western institution that was more than hundred years old was built on the savage legacy of colonialism – even if the institution claims to stand for peace and justice.

“Perhaps we deal with uncomfortable pasts by burying them, excusing them, or atoning for them,” Horton wrote.

In their recent commentary on decolonising global health for the British Medical Journal, Ali Murad Büyüm and colleagues noted that histories of slavery, redlining, environmental racism and the predatory nature of capitalism underpin the design of global and public health systems, resulting in structural, racial and ethnic inequities within Black, Indigenous and People of Color (BIPOC) communities globally.

Connecting the inequities to the COVID-19 pandemic, the authors noted that exclusionary colonialist patterns that centre around Euro-Western knowledge systems have also shaped the language and response to the pandemic, which in turn can have adverse health outcomes.

“Decolonising global health advances an agenda of repoliticising and rehistoricising health through a paradigm shift, a leadership shift and a knowledge shift,” the authors state. “While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health.”

The Genesis Of Misconceptions

For her part, Khan notes that the emergence of developed countries as the worst hit by COVID-19 (contrasting earlier predictions that countries in Africa would be the worst hit) is an indication that there is imbalance in the flow of knowledge and resources in global health.

“That was the mindset with which the global health organisations were working: ‘we need to do something to help these countries or they will crumble. But you can see how countries like Nigeria have brilliantly handled things. The political leadership has been much better’,” Khan says.

She adds that the experience of African and Asian countries that are avoiding poor outcomes in COVID-19 are not included in the writings and independent reviews on COVID-19 – often because the authors of such publications are largely people in the Global North: “It is as if the reality can be ignored. Those expertise and the skills are there and there is a lot to learn in both directions, rather than in just one direction.”

Questionable metrics for Public Health Careers

Beyond ignoring and under-representing the achievements of low-income countries in the fight against COVID-19, the need for decolonisation is also evident in the attachment of institutional brand names to successful careers in public health.

Khan notes that young scientists in developing countries have to incur exorbitant costs to be able to afford an education

that would bring them closer in line with their contemporaries in Western countries.

“For instance, the schools of global public health, and the brands that are associated with them, are largely concentrated in western countries. Employers look for those names,” Khan says.

“If you don’t have the brand name from one of those top universities, it’s much harder to progress. People from low-income countries have to pay massive fees, advancing the cycle of inequality.”

In a similar vein, she argued that papers submitted by individuals from developing countries who are not products of the elite institutions will be judged much more harshly by white reviewers.

“You will get more scrutiny, you might not be able to write very well, you might not get invited for presentations: those things that grant you credibility as an expert are much harder for people of color. So those structures are there,” Khan tells Health Policy Watch. “To get promoted, they ask for how many papers published, how many grants. Naturally, people of color will have less because to have one paper, you have to work much harder to get one grant.”

She also drew attention to the existence of an unchallenged system that ensures that people of color do not progress as quickly as their colleagues from elsewhere: “When you look at organisations, there are a lot more people of color at the bottom doing the groundwork than people at the top in senior positions.”

Changing the status quo – Equity in Career Advancement Metrics

In spite of evidence that supports of the existence of unfavorable metrics that disenfranchise BIPOC and other marginalised groups from making bigger impact in global health, there appears to be a deafening silence among the key organisations in the ecosystem – a development Khan attributed to those in charge of the organisations who favour the status-quo.

“For a long time, they’ve been able to get away with not addressing it. If you’ve got a leadership that is predominantly white and not from the country you serve, you think that’s not important. If that’s what you like because if it benefits you, why would you change it?

“There has been a lot of media attention lately so there has been a lot more scrutiny. We need to create the incentives for change,” Khan argues. “I don’t think the incentives are necessarily in there, we need to know that the change will be opposed. Nobody gives up power willingly.”

One of the changes that Khan is advocating for is a comprehensive review of the metrics being used for career advancement in global health. She tells Health Policy Watch that current metrics are such that certain people will rise to the top and others will struggle to rise to the top.

“The system doesn’t value skills,” she notes. “A good example is connection with the local context in which research or service delivery work is being conducted. Being able to speak the local language – being from the country – is given a lot less rating than it should, whereas being able to write and speak really well in English is given a lot more. And that’s why certain people will score more highly than the rest. I think the metrics do matter.”

Timing concern and what can work

The deafening silence from those who would be beneficiaries of moves to decolonise global health raises concern regarding the timing of the call, especially considering the global health ecosystem is largely preoccupied with controlling COVID-19. But Khan said the situation will not change unless it is compelled to change:“The people in power are essentially not going to change the metrics and therefore reduce their power so it favors people that do not look like them.

“I think we have to be conscious of that. People will not consciously or unconsciously reduce their own power,” Khan affirms.

To truly decolonise global health, Khan is calling for a review of the governance system in a number of global health organisations. “Broader than issues of racism and decolonisation, we are also seeing massive governance failure in terms of sexual abuse of some to these international organisations. That’s another symptom that there are people who are being exploited within these organisations that are supposed to be believing in justice and implementing justice. It just has to be done with political will,” Khan says .

Although it would take a while to systematically uproot colonisation, Khan argues that individuals have roles to play to address the narrative.

“One thing about COVID-19 is that it has shown us that if you’re okay in your bubble while other countries are not okay, it will soon spread to your little bubble,” Khan tells Health Policy Watch.

“We need resources to be spread out more equitably.”

Image Credits: Louis George 2011 , Jenny Salita, Louis George 2011 , Johns Hopkins University and Medicine, WHO African Region, Geneva Health Forum.