The art of medicine Will global health survive its decolonisation?

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The art of medicine Will global health survive its decolonisation?

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) Vol 396 November 21, 2020                                                                                                 1627
The art of medicine Will global health survive its decolonisation?

                                         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.
           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.
                                         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
         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                                                                                                                    Vol 396 November 21, 2020

                                  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.          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
                                      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        
                                                                                                                                                    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             
                                  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   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                                                                                                                                           Vol 397 March 20, 2021

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                                    (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                     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
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:  
sciences. This lesson is relevant within   Lancet Commission on Global Surgery                            advancing equitable access to diagnostics.       global-surgery
                                                                                                          Lancet 2019; 393: 2018–20. Vol 397 March 20, 2021                                                                                                                                            1059
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