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      The Rhetoric of Decolonizing Global Health Fails to Address the Reality of Settler Colonialism: Gaza as a Case in Point

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          Abstract

          This editorial critiques the existing literature on decolonizing global health, using the current assault on health in Gaza as a case in point. It argues that the failure to address the ongoing violence and blatant targeting of health facilities, personnel and innocent civilians demonstrates most clearly the limitations of an approach that is strong on rhetoric and weak on mounting a forthright challenge to the entire system supporting and perpetuating settler colonialism. We propose a more radical rethinking of the position of global health institutions within the current neoliberal system and of the systems of knowledge production that continue to underpin the existing colonial approach to the health of victims of settler colonialism.

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          Decolonising global health: if not now, when?

          Summary box The current global health ecosystem is ill equipped to address structural violence as a determinant of health. 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. While the manifestation of inequity in individual countries or regions is bound up in the local-to-global interface of historical, economical, social and political forces, COVID-19 disproportionately affects BIPOC and other marginalised communities. Aside from direct health impacts on marginalised communities, exclusionary colonialist patterns that centre 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. While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health. Introduction The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has grinded the world economy to a halt and upended health systems across the globe, contributing to disruptions in routine health services and skyrocketing rates of death.1 Against this backdrop, the pandemic highlights with renewed clarity the way structural violence operates both within and between countries. Defined as the discriminatory social arrangement that, when encoded into laws, policies and norms, unduly privileges some social groups while harming others, this concept broadens our thinking about drivers of disease.2 While the manifestation of inequity in each country or region is bound up in the local-to-global interface of historical, economical, social and political forces, COVID-19 disproportionately affects the world’s marginalised, from Black, Indigenous and People of Color (BIPOC) communities in North America to migrant workers in Singapore.3 Health outcomes related to SARS-CoV-2 infection such as access to emergency services and prolonged intensive care, capacity to prevent infection through non-medical countermeasures like handwashing and social distancing, and economic security while in lockdown are all mediated by the confluence of global, regional and local systems of oppression. This reality shows that the current global health ecosystem is ill equipped to address structural violence as a determinant of health, and the system itself upholds the supremacy of the white saviour. As early career global health practitioners, we see this pandemic as an opportunity to critically appraise what is not working and to offer an alternative vision for the future of global health. Global health needs integrated, decolonised approaches—advanced by individuals and institutions—that address the complex interdependence between histories of imperialism with health, economic development, governance and human rights. The global movement to Decolonize Global Health, led by students and other professionals, is one step towards this vision.4–8 In this commentary, we draw on examples that show how the most vulnerable and marginalised in society are ignored and exploited by design and in context-specific ways in the pandemic response. Through these examples, we call for a threefold shift in global health research, policy and practice. Structural determinants of health for the marginalised majority The disadvantaged and marginalised make up the global majority. This ‘marginalized majority’ is strategically divided and disempowered by deep-seated racial, ethnic and financial inequities that fuel structural determinants of health. These kinds of power imbalances are by design and are by no means unique to the field of global health, yet health is often the locus of where many of these inequities intersect. Globally, 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 BIPOC communities. This pandemic widens these pre-existing inequities even further. Black and Brown people make up a significant portion of the essential workforce in many settler colonial states.9 10 Yet, they are often underpaid, underinsured and more likely to live in overcrowded, polluted and food insecure conditions that further increase their risk. Consequently, these communities have faced disproportionate rates of severe outcomes and deaths due to COVID-19.11 Without acknowledging these oppressive forces, the pandemic response will lack context-specific and targeted policies to address the structural racism that enforces these health disparities. For example, Singapore’s treatment of migrant workers illustrates how ignoring structural determinants of health has disastrous consequences for both those marginalised and the broader society. Singapore’s 1.4 million migrant workers from India, Bangladesh, China and other nearby countries encompass one-third of the country’s workforce. They leave their home countries for a better chance to sustain their families, break cycles of poverty and escape archaic forms of social hierarchies like the caste system. Despite playing a pivotal role in Singapore’s development, migrant workers live in the margins of society, often cramped in dorms with 10–20 people to a room. This marginalisation led to Singapore ignoring them in its pandemic response. Initially credited as exemplary, Singapore’s success has been reversed with a current infection rate of 1000 new cases per day, attributed to a spike in infections among migrant workers. Migrant workers are touted as ‘the invisible backbone’ of Singapore, yet SARS-CoV-2 has lifted the smokescreen to reveal how little these workers are actually valued, resulting in Singapore’s failure to protect them from the virus and to protect the entire nation from a resurgence in cases.12 The impact of SARS-CoV-2 on Indigenous peoples in the USA is another potent example of how structural violence prevents equal access to health and appropriate medical care, and leads to disproportionate suffering and premature death. The systematic destruction and dispossession of Indigenous communities through violent colonial practices in the USA has left communities like the Navajo, which has among the highest infection rates in the country,13 with poor access to healthcare and a higher prevalence of comorbidities that increase their risk of contracting and dying from COVID-19. Furthermore, contemporary policies governing ethnic and racial categories in health reporting—in which Indigenous communities are often categorised as ‘other’14—skew their official death rate from COVID-19 and result in the continued erasure of these communities. Not properly accounting racial and ethnic minorities in these totals ignores the severity of the pandemic’s impact on these communities and erases the historical injustices that put them at greater risk in the first place. Colonialist patterns shape the language and response to the pandemic Aside from direct health impacts on marginalised communities, colonialist patterns that centre Euro-Western knowledge systems have also shaped the language and response to the pandemic—which, in turn, can have adverse health outcomes. The occupiers of the highest tiers of the social hierarchy have long used scapegoating in times of crisis to divert attention from root causes of the crisis at hand. During the Black Death, Jewish communities were systematically targeted; during the AIDS pandemic, men who have sex with men and others in the lesbian, gay, bisexual, transgender and queer community were ostracised; and now, in 2020 with the outbreak of SARS-CoV-2, we see a repeat of history.15 With labelling such as the ‘Wuhan Virus’ or the ‘Chinese Virus’, Chinese and other East Asian populations worldwide are being scapegoated and facing discrimination. Another way COVID-19 has further been racialised to uphold colonialist beliefs is seen with international news headlines such as ‘Why don’t Africans have the disease?’ This attitude reveals an assumption that countries described as the ‘Global South’ could not be doing better than the so-called ‘Global North’.16 As another example, French scientists suggested that Africa be the testing grounds for SARS-CoV-2 vaccine trials, invoking imperialist and colonialist ideologies that ‘some lives were more valuable than others.’ How, in March 2020 when this statement was made, could anyone practising global health deem it appropriate to use Black and Brown communities as ‘guinea pigs’ to promote the health of white, colonialist counterparts?17 The answer lies in the persistence of racist patterns that have yet to be fully dismantled. Numerous success stories emerging from the ‘Global South’ counter this false narrative of Eurocentric superiority. Kerala, for example, a southwestern state in India, implemented highly coordinated state-wide lockdowns and test-and-trace strategies to effectively contain and control the virus.18 Among all the negative media coverage of India so far, however, this narrative of success is rarely highlighted or acknowledged. Likewise, in Africa, Senegal has become a leader in their pandemic response strategies, which include innovative technologies to reach entire populations with affordable tests for the virus. International coverage of the continent, however, instead has focused on the assumed inevitable failure of African nations to effectively respond to the pandemic, failures which are often caused by limited resources resulting from colonialism and modern-day imperialism. This representation is obviously biased, and is so because those with power to control the narrative around the pandemic continue to be disproportionately not from or based in the ‘Global South’.19 20 This imbalance, driven by what WHO Director General Tedros Adhanom Ghebreyesus termed a ‘colonial hangover’, also plays out in what gets recommended as a good pandemic response strategy.21 Global health institutions based in the ‘Global North’, often lacking representation of key communities at the decision-making table, end up perpetuating a Eurocentric worldview that does not adequately consider most of the world’s needs. The notion of simply ‘copy-pasting’ strategies like lockdowns and social distancing measures does not work in spaces like cramped migrant worker dormitories, refugee camps, urban slums or anywhere else the poorest and most marginalised are forced to reside. How can a family of 15 lock down in a slum complex that houses 700 000 others? How can you practise good hygiene such as handwashing when water itself can be a scarce commodity? When the people in power represent only those with social dominance, the health needs of the marginalised majority inevitably get overlooked. In the wake of the pandemic, these colonial trends that we see time and time again must be reversed. A decolonising agenda for health equity, beginning with COVID-19 To uproot these sources of health inequity, all practitioners and researchers should leverage the disruptions caused by this pandemic to more critically reflect on their actions. More and more voices call for recognising and redressing these imbalances in global health.22–24 From activists to professors, non-governmental organisation leaders to clinicians, a decentralised alliance is building, demanding that global health practitioners meaningfully engage with global and local structures that drive health inequities. Within that coalition, the student-led decolonising global health movement serves an important but limited function: to help create space for critical, anticolonial reflection within large, influential and privileged institutions, agencies and organisations, so far often in high-income countries (HIC), that are responsible for driving global health discourse, ‘knowledge’ and funding flows.25 This movement advances an agenda of repoliticising and rehistoricising health. We believe that the movement broadly calls for the following: Paradigm shift: Repoliticise global health by grounding it in a health justice framework that acknowledges how colonialism, racism, sexism, capitalism and other harmful ‘-isms’ pose the largest threat to health equity. Without confronting the impact these interlocking systems have on health, global health activity, despite best intentions, remains complicit in the ill health of the world’s marginalised. A paradigm shift involves individuals and institutions acknowledging that disease cannot be extracted or isolated from broader systems of coloniality.26 27 Organisations and donors should adapt their missions, programming and structures to account for this reality. Fundamentally, this shift means changing who sits at the table and rebuilding parts of the table itself. Leadership shift: Leadership at global agenda-setting institutions does not reflect the diversity of people these institutions are intended to serve. First, the ‘Global North’ needs to ‘lean out’ on an individual, national and institutional level to stop reproducing racist and colonialist ideologies.28 Unsurprisingly, experiences from the ‘Global South’ show that it is a hotbed of innovation, and leaders in the ‘Global South’ must be recognised and elevated for their contributions. Second, gender disparities in global health leadership need to be addressed and remedied. In many global health institutions, women, especially women of colour, are under-represented and their voices are excluded in policy and programmatic formulation.29 30 A leadership shift would include more equitable representation in academic journals, leadership roles and faculty make-up, reflected, for example, in equitable first authorship positions for collaborators from the ‘Global South’ and women.31 32 Knowledge shift: To avoid perpetuating the kind of racist and colonialist pandemic response we see with COVID-19, it is vital to ensure knowledge flow is not unidirectional, but instead reciprocal with contributions from the ‘Global South’ driving discussions and practice, both locally and globally; a twofold knowledge shift.33 The first includes teaching students about inequitable global disease burdens while creating an enabling environment for critical inquiry into the racist and colonial histories that gave rise to these disease burdens. The second is to bridge geopolitical imbalances in global health education. For example, global health training programmes and knowledge resources are mostly offered in the English language, in HICs and at great cost, thus limiting access for people of other languages, and from less privileged backgrounds. To promote anticolonial thought by encouraging training and knowledge sharing without these obstacles, we need to change existing platforms and create new learning platforms for global health. Conclusion The pandemic response reveals with stark and sobering clarity that current paradigms of global health equity are insufficient in counteracting structural oppression. By focusing on individual risk factors and siloing funding based on disease, global health agendas—including pandemic responses—ignore how health risks are shaped structurally by laws, policies and norms, ranging from regional trade agreements and immigration policies to racial discrimination and gender-based violence. Structural inequities reproduced within the global health system itself—such as over-representation of affluent white men from HICs in global health leadership positions34—highlight the lack of critical engagement with the geopolitical determinants of health disparities. While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health. A student-led decolonising movement is one step. Now, the movement must expand in numbers and scope to create a more just and equitable future.
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            Decolonising global health in 2021: a roadmap to move from rhetoric to reform

            Decolonising global health was a hot topic in 2020. It was the subject of more than 50 academic articles between January and December 2020, appeared as a new area covered in numerous conferences, and featured in public statements by leaders of global health organisations. Although its aims have not been formally defined, we see ‘decolonising global health’ as a movement that fights against ingrained systems of dominance and power in the work to improve the health of populations, whether this occurs between countries, including between previously colonising and plundered nations, and within countries, for example the privileging of what Connell calls research-based knowledge formation over the lived experience of people themselves.1 2 It is well documented—although often overlooked—that global health has evolved from colonial and tropical medicine, which were ‘designed to control colonised populations and make political and economic exploitation by European and North American powers easier’.3 The operations of many organisations active in global health thus perpetuate the very power imbalances they claim to rectify, through colonial and extractive attitudes, and policies and practices that concentrate resources, expertise, data and branding within high-income country (HIC) institutions.4 5 As a group of global health practitioners from different backgrounds, we reflect on our personal and professional experiences of systems and processes that institutionalise power imbalances. In this article, we propose a roadmap for global health practitioners, like us, who want to see rhetoric turn into reforms, focusing on systemic changes needed in organisations led from HICs. This is important now, because the flurry of statements and virtue signalling in 2020, could, in fact, be counterproductive, if this builds an impression of commitment that allows the leadership of organisations in HICs to escape accountability. We fully acknowledge that colonial mindsets and systems that perpetuate power imbalances in global health are not confined by geographical boundaries; they are found in organisations based in low/middle-income countries (LMICs) too. While we focus here on one part of the problem and the solution, we encourage individuals and groups in LMICs to challenge the status quo. We start by laying out the uncomfortable honesty that is needed. Dialogues centred on the notion that all stakeholders are always supportive of the decolonisation agenda can be serious impediments to progress. It is important to acknowledge that there will be conflict and discomfort. People in powerful positions, who have likely benefited from current systems, may be concerned about systemic change, be it overtly or covertly. These acknowledgements are essential for moving forward to more impactful and meaningful discussions in 2021. Once we acknowledge that there will be supporters and opponents of decolonising global health, it becomes clear that a social justice argument or that increasing diversity of leadership alone will likely be insufficient to initiate widespread reforms that redistribute power or resources. Drawing parallels with the feminist movement, it is often the case that an individual accepts the tenets of feminism, while the individual, at the same time, treats women unfairly. The case for systemic change to enable equality in women’s opportunities to hold leadership positions benefited from an emphasis on the impacts of feminist leadership on the effectiveness of organisations as well; framing the argument only in terms of human rights and justice was not enough for all people and organisations.6 Thus, dispelling the myth that everyone working in global health is focused predominantly on health equity and capacity building will allow us to approach the reforms we are seeking with realistic expectations about barriers, incentives and how to frame the issue. The ‘decolonising global health’ movement may benefit from finding strength in numbers by identifying like-minded allies across other progressive social movements targeting system-wide change based on equity, such as the feminist movements. With the above in mind, we propose steps that global health practitioners could take to drive reforms. Step one, identify specific ways in which organisations active in global health play interlinked roles in perpetuating inequity—see illustrative examples in table 1. We recognise that the global health sector is broad, encompassing organisations in the public and private domains. These organisations range from small non-governmental organisations (NGOs) to large transnational bodies. An honest and critical examination of the role each organisation plays in maintaining asymmetries of power is required. Table 1 Examples of ways in which global health organisations based in high-income countries can perpetuate inequities and systemic changes needed Example of practice that perpetuates inequities Example of change needed Limited participation of LMIC experts and community representatives in the governance structures and advisory bodies of organisations focusing on improving health in LMICs. The majority of powerful positions on governing bodies and decision-making panels of global health organisations should be held by people with the relevant in-country (or regional) expertise and lived experience of the main health issues, contexts and geographies that the organisation focuses on. Governing bodies should have diversity in thought, gender, social, geographical and ethnic backgrounds. They should be selected transparently with input from stakeholders that the organisation seeks to serve. Arbitrary choice of interventions or research topics with, little coordination or engagement with people on the receiving end, leading to top-down health programmes that cannot be sustained and can perpetuate inequalities in communities. Decentralisation of resource allocation and programme design to better engage communities served. Keeping global level staff as technical advisers and coordinators rather than decision-makers, allowing sovereignty of patients and communities while supporting mutual learning. Moving away from a biomedical model of global health programmes towards internalisation and integration of local knowledge, indigenisation of assessments and solutions, and following the lead of the affected communities in the assessment of their problems and the appropriate application of medical and public health evidence to their situations Typically place European or North American ‘experts’ with minimal experience working in the project setting in leadership positions, with a staffing model that assumes they are able to generate more valuable insights than those with local or indigenous expertise. Ensure that selections are made on the basis of a range of positive attributes, including a minimum level of local intelligence which can be judged considering factors such as: years living and working in the country or region; knowledge of local language(s); outputs of long-term collaborations. Staff, offices and other resources are based in high-income countries when they could instead be directing resources and employment opportunities to LMICs. More equitable geographical concentration of resources—including staff and offices—and decision-making power, reflecting the geographical focus of the organisations’ work. Funding application evaluation panels without or with limited representation from affected communities or stakeholders in which work will be done; grants awarded without due consideration for partnership ethics. A wider range of experts should be in decision-making positions for grant evaluations, and assessments should be more transparent; funding agencies should develop and provide frameworks for ethical and equitable partnerships; funding should be conditional on commitment to uphold, and evidence of, ethical and equitable partnership practice. LMIC, low/middle-income country. Step two, publish a clear list of reforms required to decolonise global health practice, so that organisations that are committed to moving beyond statements can better respond to the decolonisation agenda in a more proactive and coordinated way. Step three, linked to the reforms identified, develop metrics to track the progress of organisations active in global health and transparently share findings via different public channels. Publishing sets of actions and metrics that allow (or force) organisations to monitor progress towards their commitments is crucial for holding them accountable to these commitments.7 Transparent reporting of these metrics is a core component of accountability mechanisms that are sorely needed in the global health sector. Although examples of actions taken to address the practices that perpetuate inequities outlined in table 1 are scarce, documenting those that do exist is valuable. We highlight two examples to illustrate the types of actions that can be taken by organisations active in global health. First, with respect to the composition of governing bodies, the 20-member Board of The Global Fund mandates representation from NGOs and affected communities, with voting rights.8 Second, an example of more equitable geographical concentration of resources by organisations was the relocation of Oxfam International’s headquarters to Kenya from the UK in 2014. Executive Director at the time, Winnie Byanyima, said the move reflected the need ‘to shift [Oxfam’s] centre of leadership and to strengthen Southern voices within its decision-making’.9 We emphasise that the impacts of such changes on the decolonising agenda need to be assessed, and this is where metrics are critical. To achieve the steps outlined in our roadmap, we are calling for an Action to Decolonise Global Health (ActDGH) collective that will work towards driving reforms in organisations headquartered in HICs. We welcome collaboration and contribution to the collective (http://decolonise.health). For reforms to be realised, we recognise that global health practitioners must play a role in the cultural transformation needed, whereby an influx of new cultural elements and values enables a shift away from a dominant, colonialist culture in the global health sector that attempts to assimilate other cultures within a Western, ethno-centrist and neoliberal approach to global health practice. There is an opportunity to build on the momentum of 2020, which has been instrumental in drawing widespread attention to unjust practices in global health. But rhetoric is far easier than reform when power and privilege is at stake. Reform will require not only identifying specific deficiencies within the current global health sector, but also actions to radically change the prevailing systems,10 so that the organisations that currently dominate global health end up being those that demonstrably address needs of people they claim to serve. In 2021, we need to see action and evidence of progress.
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              Decolonizing global health: what should be the target of this movement and where does it lead us?

              The current decolonizing global health movement is calling us to take a post-colonial perspective at the research and practice of global health, an area that has been re-defined by contemporary scholars and advocates with the purpose of promoting equity and justice. In this article, we summarize the main points of discussion from the Symposium organized by the editorial board of Global Health Research and Policy, convened in July 2021 in Wuhan, China. Experts participating in the symposium discussed what decolonizing global health means, how to decolonize it, and what criteria to apply in measuring its completion. Through the meeting, a consensus was reached that the current status quo of global health is still replete with various forms of colonial vestiges–ideologies and practices–, and to fully decolonize global health, systemic reforms must be taken that target the fundamental assumptions of global health: does investment in global health bring socioeconomic development, or is it the other way around? Three levels of colonial vestiges in global health were raised and one guiding principle was proposed when thinking of solutions for them. More theoretical discussion needs to be explored to guide practices to decolonize global health.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – original draftRole: Writing – review & editing
                Journal
                Int J Health Policy Manag
                Int J Health Policy Manag
                Kerman University of Medical Sciences
                International Journal of Health Policy and Management
                Kerman University of Medical Sciences
                2322-5939
                2024
                09 April 2024
                : 13
                : 8419
                Affiliations
                Sustainable Health Unit, University of Oslo, Oslo, Norway.
                Author notes
                [* ] Correspondence to: Eivind Engebretsen Email: eivind.engebretsen@ 123456medisin.uio.no
                Author information
                https://orcid.org/0000-0001-9455-110X
                https://orcid.org/0000-0001-5724-6229
                Article
                10.34172/ijhpm.2024.8419
                11607526
                39099519
                9d0f19e6-a2e7-4231-a4af-2938af182352
                © 2024 The Author(s); Published by Kerman University of Medical Sciences

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 11 January 2024
                : 12 March 2024
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                Editorial

                global health,decolonization,settler colonialism,gaza,palestine,politics of health

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