The art of medicine Will global health survive its decolonisation?
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Perspectives
The art of medicine
Will global health survive its decolonisation?
There are growing calls to decolonise global health. This persisting disregard for local and Indigenous knowledge,
process is only just beginning. But what would success pretence of knowledge, refusal to learn from places and
look like? Will global health survive its decolonisation? This people too often deemed “inferior”, and failure to see
is a question that fills us with imagination. It is a question that there are many ways of being and doing. Supremacy
that makes us reflect on what Martin Luther King Jr saw is there in persisting colonial and imperialist (European
when he said in 1968, in the last speech he gave before and otherwise) attitudes, in stark and disguised racism,
he was killed, that “I’ve been to the mountaintop…and White supremacy, White saviourism, and displays
I’ve seen the Promised Land.” If what he saw was an equal, of class, caste, religious, and ethnic superiority, in
inclusive, and diverse world without a hint of supremacy, the acquiescing tolerance for extractive capitalism,
then, that world is still elusive. Similarly, an equal, patriarchy, and much more.
inclusive, just, and diverse global health architecture Indeed, supremacy persists in the ways of seeing and
without a hint of supremacy is not global health as we assumptions that underpin global health practice. It is a
know it today. supremacist way of seeing and doing when we entertain
What we know as global health today emerged as an implicit hierarchical assumptions—for example, about
enabler of European colonisation of much of the rest the headquarters of a global health organisation being
of the world. It has since taken on different forms— more important than its regional or country offices.
for example, colonial medicine, missionary medicine, Supremacy manifests in seeing the big as superior
tropical medicine, and international health—but it is to the small—for example, in the focus on national
yet to shed its colonial origins and structures. Even governments when subnational governments are more
today, global health is neither global nor diverse. More consequential and closer to the ground. And supremacy
leaders of global health organisations are alumni of is enacted when a greater value is placed on research by
Harvard than are women from low-income and middle- HIC or distant experts than the knowledge of those with
income countries (LMICs). Global health remains much lived experience.
too centred on individuals and agencies in high-income Will global health survive its decolonisation?
countries (HICs). Perhaps. But only if its practitioners commit to its
A future in which global health is decolonised would be true transformation. A crucial first step is recognising
one in which there are no longer pervasive supremacist that ours is a discipline that holds within itself a deep
remnants of colonisation within global health practice. contradiction—global health was birthed in supremacy,
But how do we imagine such a world? The calls for equity but its mission is to reduce or eliminate inequities
and justice in global health practice need to be matched globally. To transcend its origins, global health must
with a bold vision of the future. What vision can global
health practitioners rally around and work towards? As
the struggle for equity and justice continues, those in
power are likely to fight back—or respond with evasions,
token concessions, and changes in appearance but not
in substance. Perhaps, a clear vision of what equity and
justice looks like can help global health practitioners
overcome such inadequate responses.
To decolonise global health is to remove all forms of
supremacy within all spaces of global health practice,
within countries, between countries, and at the global
level. Supremacy is not restricted to White supremacy
or male domination. It concerns what happens not only
between people from HICs and LMICs but also what
happens between groups and individuals within HICs
and within LMICs. Supremacy is there, glaringly, in how
AFP/Getty Images
global health organisations operate, who runs them,
where they are located, who holds the purse strings,
who sets the agenda, and whose views, histories, and
knowledge are taken seriously. Supremacy is seen in Martin Luther King Jr (1929–68)
www.thelancet.com Vol 396 November 21, 2020 1627
Perspectives
become actively anti-supremacist, and also anti- health. In particular, women in the Global South, who
oppressionist and anti-racist. Equity and justice involve form the majority of the global health workforce, are
flipping every axis of supremacy on its head. proportionately represented in leadership.
The supremacy that manifests in global health is not In this future that we can barely see, diversity and
peculiar to global health. Entrenched in the fibre of past inclusiveness are not enough. The focus is not only on
and present social and political systems, supremacy re- things that can be easily measured, but also on things
creates the inequities that global health seeks to undo. It that matter but cannot be easily counted—for example,
also generates funding, jobs, and training opportunities how new voices are heard and prioritised and how
in global health. But rather than re-enact and reflect the people who now make the field diverse go about
the world back to itself in the fullness of entrenched reshaping it for the better. In this imagined world,
oppression, global health must offer the world a better representation is as important as how it alters the
version of itself. Global health must free itself from agenda; what is on the table is as important as who is
the persisting blindness of supremacy and embrace its around the table. It is a landscape that serves the most
alternative—equity and justice. disadvantaged and recognises that you cannot truly help
In the promised land that we imagine, academic global or support people, be their allies and enablers, without
Further reading
health looks very different. Imbalance in authorship seeing the world through their eyes and seeing yourself
Abimbola S. The foreign gaze:
authorship in academic global
within partnerships between HICs and LMICs is a thing as they see you. The imaginative leap that allows a
health. BMJ Glob Health 2019; of the past. Journals have been transformed. Knowledge global health practitioner to consider their position or
4: e002068 platforms are now decentralised and democratised. No an issue from varying viewpoints requires respect and
Abimbola S. On the meaning of longer exclusive, high-impact western journals now humility. Empathy is not enough. The desire to make the
global health and the role of
global health journals.
exist among a multitude of go-to places, most of which world a better place, however genuine and heartfelt, is
Int Health 2018; 10: 63–65 are now based in the Global South. In our reimagined not enough. Respect and humility are vaccines against
Affun-Adegbulu C, Adegbulu O. world, the traditional mindset in global health—that supremacy.
Decolonising global (public) expertise flows from HICs to LMICs—is a thing of the It is a future that we can only dream of. This vision is a
health: from western universalism
to global pluriversalities.
past. Many academic institutions in the Global South mere start—a sketch of a dream—an invitation for others
BMJ Glob Health 2020; 5: e002947 are as influential as those in the Global North—with to join us, to dream more vividly, and to chart a path to
Büyüm AM, Kenney C, Koris A, a clear mission to serve the disadvantaged across making such a dream a reality. We see many young global
Mkumba L, Raveendran Y. both settings. There is no dependence, only mutual health practitioners who share these dreams. They are
Decolonising global health: if not
learning. Trainees from HICs are eager to study global not afraid to ask uncomfortable questions. Established
now, when? BMJ Glob Health
2020; 5: e003394 health in LMICs to learn directly from experts who are global health practitioners, including us, must do better,
Global Health 50/50. Power, closest to the problems and closest to the solutions. even if it means “leaning out” to make space for young
privilege and priorities: Global Global health degrees are accessible to those who need and minoritised leaders who are better positioned to
Health 50/50 report 2020. them the most and are taught by those who are at the imagine global health anew.
https://globalhealth5050.org/
2020report/(accessed front lines. Will global health survive its decolonisation? Well, if the
Nov 9, 2020) It is a different world. Reports of racism in global future of global health is more of the same with some
Horton R. Offline: Is global health organisations are a thing of the past. These cosmetic changes to disguise supremacy, it would have
health neocolonialist? organisations are no longer White-led, White-dominated failed. But if the future is a radical transformation, then
Lancet 2013; 382: 1690
institutions in HICs but have reoriented their operations global health would be unrecognisable. We may even
Jumbam DT. How (not) to write
about global health.
to be closer and accountable to the people they serve. have to give it a new name. The goal of global health
BMJ Glob Health 2020; 5: e003164 They are run by people who are local to the issues should not be to survive its decolonisation, but to rise up
Mbembe A. The state of and local knowledge takes pre-eminence. Governed and live up to the pressing demands of its mission. The
South African political life. inclusively and responsively, these organisations now reality of Martin Luther King Jr’s dream of a just and equal
Africa Is a Country, Sept 19, 2015.
https://africasacountry.
focus on organic change, as allies and enablers of local world would not have been any different. It is a different
com/2015/09/achille-mbembe- processes and learning. Rather than seeing global health world, a different global health.
on-the-state-of-south-african- as charity or saviourism, they seek to push for health as a
politics (accessed Nov 9, 2020)
fundamental human right, locally and globally. Seye Abimbola, *Madhukar Pai
Pai M. Global health research
needs more than a makeover.
In this imagined future, global health practitioners School of Public Health, University of Sydney, Sydney, NSW,
Forbes, Nov 10, 2019 in HICs and those who are otherwise privileged, have Australia (SA); and School of Population and Global Health and
Pai M. Global health needs to be embraced an appropriately modest view of their McGill International TB Centre, McGill University, Montreal,
global and diverse. Forbes, importance, and mastered the art of critical allyship, QC H3A 1A2, Canada (MP)
March 8, 2020
where they see their primary role as allies and enablers madhukar.pai@mcgill.ca
Svadzian A, Vasquez NA,
rather than leaders. Rather than drawing from a limited @paimadhu
Abimbola S, Pai M. Global health
degrees: at what cost? talent pool of elite HIC institutions, Black, Indigenous, SA is Editor-in-Chief of BMJ Global Health and MP is on its editorial board;
MP also serves on the editorial board of The Lancet Infectious Diseases.
BMJ Glob Health 2020; 5: e003310 and other people of colour are the real leaders of global
1628 www.thelancet.com Vol 396 November 21, 2020Correspondence
1 Joint Committee on Vaccination and in directing global health endeavours do production of health or with the political
Immunisation. Optimising the COVID-19
vaccination programme for maximum short-
not have the opportunities or training arguments based on myriad values that
term impact. Jan 26, 2021. https://www.gov. to prove why or how they are valuable fall outside of the traditional medical
uk/government/publications/prioritising-the- in meaningful ways to academia. and health sciences. It is impossible
first-covid-19-vaccine-dose-jcvi-statement/
optimising-the-covid-19-vaccination- Under some circumstances, they can be to decolonise global health if crucial
programme-for-maximum-short-term-impact actively oppressed. geopolitical analyses, and the impact
(accessed Jan 29, 2021).
2 Polack FP, Thomas SJ, Kitchin N, et al. Safety and
There is a refusal to learn from local on relationships between high-income
efficacy of the BNT162b2 mRNA COVID-19 populations, especially those from countries (HICs) and low-income and
vaccine. N Eng J Med 2020; 383: 2603–15. the margins of society, and ethnic middle-income countries (LMICs),
3 Walsh EE, Frenck RW, Falsey AR, et al.
Safety and immunogenicity of two RNA-based superiority exists within societal, remain chronically marginalised.
COVID-19 vaccine candidates. N Engl J Med political, and academic structures in Additionally, decolonising global
2020; 383: 2439–50.
both HICs and LMICs, which is rising health extends beyond relations
4 Treibel TA, Manisty C, Burton M, et al.
COVID-19: PCR screening of asymptomatic amid right-wing conservatism in between LMICs and HICs; it is also
health-care workers at London hospital. Lancet some settings. How do we effectively about the relationships within them.
2020; 395: 1608–10.
5 Reynolds CJ, Swadling L, Gibbons JM, et al.
empower valuable leaders to push Decolonisation is fundamentally
Discordant neutralizing antibody and T cell forward necessary global health about redressing inequity and power
responses in asymptomatic and mild measures when they are restricted imbalance. It cannot be achieved
SARS-CoV-2 infection. Sci Immunol 2020;
5: eabf3698. from the outset? without also addressing gender inequity,
Colonisation has left a pervasive racism, and other forms of structural
mark. Its legacy in LMICs still needs to violence. The colonised also have to be
Undoing supremacy in be unpicked. Creating truly equitable at least as reflective about the status
global health must involve diverse quo as the colonisers. This mindset goes
global health will groups of people who view challenges beyond engagement and participation
require more than through differing lenses from their between HICs and LMICs, to disrupting
decolonisation backgrounds, lived experiences, and the norms of dependency within LMICs
skills, and who have wider, inclusive that enable the inequities and replicate
I read with interest Seye Abimbola visions that do not focus on individual the hierarchies of neocolonialism. In
and Madhukar Pai’s Perspective. 1 It career success and are not at the mercy real terms, LMICs must confront their
provides an enlightening and hopeful of prescribed academic agendas in HICs. own internal power relations inherent
vision of decolonised global health I declare no competing interests. in the discourse of immutable culture,
detangled from supremacy in its many which protect cronyism, tribalism, poor
Keerti Gedela
forms. However, it left me feeling that keertigedela@gmail.com
governance, and patriarchy.
the vast mark that colonisation has Ultimately, a decolonised global
Chelsea and Westminster NHS Foundation Trust,
left on society, politics, and system London SW10 9NH, UK health can only exist within a broader
hierarchy within low-income and 1 Abimbola S, Pai M. Will global health survive its
geopolitical and economic environment
middle-income countries (LMICs) has decolonisation? Lancet 2020; 396: 1627–28. that supports rights, equity, and justice.
been less considered. Without paying We declare no competing interests.
due consideration to the challenges Seye Abimbola and Madhukar
*Pascale Allotey, Daniel D Reidpath
of supremacy and oppression within Pai 1 describe eloquently how, for pascale.allotey@unu.edu
LMICs, we cannot realistically equalise historical reasons, global health
International Institute for Global Health,
global health and progress to ensure is operationalised as a saviourism United Nations University, Bandar Tun Razak,
that it upholds health equity and social model. To redress the balance of Kuala Lumpur 56000, Malaysia (PA); International
justice. power between saviour and saved, Centre for Diarrhoeal Disease Research Bangladesh,
Dhaka, Bangladesh (DDR)
Globally, we observe how rich they envision a utopic global health
1 Abimbola S, Pai M. Will global health survive its
academics in high-income countries fuelled by respect and humility, and decolonisation? Lancet 2020; 396: 1627–28.
(HICs), particularly from the UK and motivated by an adherence to values
USA, tend to get richer. For example, based on rights, equity, and justice. Authors’ reply
the ways in which global health funding Unfortunately, the disciplines that We thank Keerti Gedela as well as
and publication are dominated by dominate global health attend to the Pascale Allotey and Daniel Reidpath
prominent academics and high-income causes of and solutions to disease for their responses to our Perspective
Submissions should be prestigious institutions mean that endpoints on the health and wellbeing on decolonising global health.1 We
made via our electronic
submission system at
worthy work can be dismissed when spectrum. Such disciplines have not welcome and completely agree
http://ees.elsevier.com/ teams are less valued. Importantly, many engaged adequately with a crucial with the points they highlighted
thelancet/ individuals from LMICs who are valuable understanding of the sociostructural for additional emphasis: greater
1058 www.thelancet.com Vol 397 March 20, 2021Correspondence
focus on the local dynamics of how HICs and LMICs, as it is in global and and the ongoing Lancet Commission
supremacy creates health (in)equity international affairs. on Diagnostics.2
within countries, and expansion Ultimately, as both Correspondences Total hip arthroplasty is considered
of our disciplinary focus to include highlight, the locus of the change we one of the most successful and
research methods to understand how seek in global health is within not cost-effective surgical interventions
the geopolitics of supremacy creates only HICs but also LMICs. In research ever developed.3 Furthermore, even
health (in)equity between countries partnerships or funding decisions, it though the mantra we treat patients
and to incorporate the knowledge held is not enough that HIC actors lean and not x-rays remains a core value in
by the intended beneficiaries of global out.3 LMIC actors must also lean in— orthopaedic surgery, treating patients
health efforts. eg, by calling out parachute research, with osteoarthritis without access
As we emphasised, 1 colonialism demanding reciprocity, setting up their to diagnostics is near to impossible.
and power asymmetry between high- own high-impact academic journals, Despite the benefits of diagnostics,
income countries (HICs) and low- or building high-quality schools of economic constraints in low-income
income and middle-income countries public health. However, doing so and middle-income countries severely
(LMICs) is but one manifestation requires funding and political action, restrict access to surgical care and
of supremacy. Therefore, undoing which national and international diagnostic technology.2,4 We believe
supremacy will require much more power relations might obstruct, but that the work done by the Lancet
than decolonisation. Nevertheless, against which we must fight because Commission on Global Surgery
decolonisation is a good place to start combating all forms of supremacy and the Lancet Commission on
given its role in the creation of global should be synonymous with global Diagnostics can meaningfully inform
health, and how coloniality persists in health. the work of the Lancet Commission on
the field. The structures of supremacy SA is editor-in-chief of BMJ Global Health and MP is Osteoarthritis.
and oppression that manifest between on its editorial board. MP also serves on the editorial Additionally, we would like to
board of The Lancet Infectious Diseases.
countries are reflected within countries ask the commissioners to consider
in the supremacist institutions of, for Seye Abimbola, *Madhukar Pai inviting a paediatrician or paediatric
example, class, racism, casteism, and madhukar.pai@mcgill.ca (orthopaedic) surgeon to further
patriarchy. Although the historical School of Public Health, University of Sydney, the transdisciplinary nature of
origins and underlying philosophy and Sydney, NSW, Australia (SA); Department of the Commission. Such an expert
Epidemiology and Biostatistics, School of
rationale of these institutions might Population and Global Health and McGill
could provide valuable insights on
differ, they are similar in how they International TB Centre, McGill University, Montreal, paediatric conditions that predispose
oppress and maintain inequities in (the QC H3A 1A2, Canada (MP) osteo a rthritis, such as scoliosis,
circumstances that create) health. In 1 Abimbola S, Pai M. Will global health survive its developmental dysplasia of the hip,
decolonisation? Lancet 2020; 396: 1627–28.
addition to national spaces, oppressive Legg-Calvé-Perthes disease, or septic
2 Richardson ET, Farmer P. Epidemic illusions: on
power relations of supremacy are writ the coloniality of global public health. London: arthritis, and possible pathways for
large in intranational spaces too. The MIT Press, 2020. prevention and mitigation.5
3 Pai M. Men in global health, time to ‘lean out.’
To understand how geopolitics Nov 19, 2020. https://naturemicrobiology
We wish the commissioners all the
perpetuate inequities and how community.nature.com/posts/men-in-global- best in their important work, and we
incorporating local knowledge can health-time-to-lean-out (accessed Jan 11, 2021). hope that they are willing to consider
help to reduce inequities in global our reflections and suggestions.
health, we must undo another MP is supported by a grant from the Belgian Kids’
important supremacy in the field— Osteoarthritis in 2020 Fund for paediatric research. JGM is a commissioner
on the Lancet Commission on Global Surgery and
ie, the disciplinary supremacy that
places the quantitative biomedical
and beyond the Lancet Commission on diagnostics. All other
authors declare no competing interests.
and epidemiological sciences (often We applaud the bold move of creating
*Manon Pigeolet, Anusha Jayaram,
Dr P Marazzi/Science Photo Library
led by HICs) above the qualitative the Lancet Commission on Osteo
Kee B Park, John G Meara
political and anthropological sciences.2 arthritis, an often forgotten illness.1
manon.pigeolet@outlook.com
One of the many great lessons of Globally applicable and acceptable
The Program in Global Surgery and Social Change,
the COVID-19 pandemic is that solutions need transdisciplinary Department of Global Health and Social Medicine,
achieving equity in (the circumstances action, which the Commission has Harvard Medical School, Boston, MA 02115, USA
that create) health is at least as clearly thought about, given its diverse 1 Hunter DJ, March L, Chew M. Osteoarthritis in
much a domain of the political and professional make-up. In this line of 2020 and beyond: a Lancet Commission.
Lancet 2020; 396: 1711–12. For the Lancet Commission on
anthropological sciences as it is one thought, we would like to highlight 2 Wilson ML, Atun R, DeStigter K, et al. Global Surgery see https://www.
of the biomedical and epidemiological two other Lancet Commissions, the The Lancet Commission on diagnostics: thelancet.com/commissions/
sciences. This lesson is relevant within Lancet Commission on Global Surgery advancing equitable access to diagnostics. global-surgery
Lancet 2019; 393: 2018–20.
www.thelancet.com Vol 397 March 20, 2021 1059You can also read
