(Purse) Strings Attached From Dependency to Decolonization in Global Health

COVID-19 is reminding us that global health has long operated a model in which Africans are treated as subjects of a quasi-philanthropic complex that, in turn, feeds one of the largest industries in the world.

Amid the cacophony of ‘wake-up calls’ triggered by COVID-19, the colonial dynamics of global health have particularly struck a nerve on the African continent. These concerns are not new, simply underscored in acute ways that make them difficult to deny or ignore. The pandemic is reminding us that global health—which originated in the colonial-era field of ‘tropical medicine’—has long operated a model in which Africans are treated as subjects of a quasi-philanthropic complex that, in turn, feeds one of the largest industries in the world.

This model is increasingly subject to a swell of critical scrutiny from within the field. At the global level, American and European institutions have ironically—but not surprisingly—occupied a prominent space in that critique. Over the past year, several universities including Harvard, Duke, Edinburgh, Johns Hopkins and Sweden’s Karolinska Institute have organized conferences under the banner of decolonizing global health, more recently collaborating with African institutions such as the University of Pretoria’s Journal of Decolonizing Disciplines and the University of Rwanda.

At the heart of these conversations are what the Duke Decolonizing Global Health working group described earlier this year as ‘frustrations with how global health continues to be taught and practiced in depoliticized, ahistorical, and uncritical ways’. Arguing that the progressive framework of global health equity—which has gained popularity in recent years due to its emphasis on the socio-economic drivers of health disparities—is not enough, they instead proposed a more radical engagement with ‘larger structures of oppression and our collective roles in upholding […] the organizational apparatus of the current globalized world order’. This, in turn, demands rigorous political engagement at every level, from the intimate to the macro-economic. ‘You can’t talk about decolonization if you’re not going to name the root causes of oppression’, says Tlaleng Mofokeng, a South African medical doctor who recently became the first African woman to be appointed as United Nations Special Rapporteur on the right to health. ‘Oppressive systems such as racism, sexism, capitalism […] the point is not to just make them less violent, because it’s impossible. You have to actually end them.’

While this imperative lies at the heart of decolonizing healthcare, says Mofokeng, it is undercut by the fact that many benefit from oppressive systems—and health is not exempt from this. Medicine, she points out, has always been used as a political tool, and needs to be examined through the lens of the broader socio-economic realities in which it is deployed. The reliance of African health systems on foreign aid is one of those realities. ‘It’s shocking,’ she says, ‘the philanthropy-cation of healthcare.’

In May, The Lancet, one of the most influential medical journals in the world, added its voice to calls for decolonization in an editorial that urged global health actors to ‘reflect on practices that have their origins in nineteenth-century imperialism and replace them with new systems that are rooted in values of recognition, reciprocity, and respect.’ But while criticizing asymmetrical power structures, the editorial inadvertently illustrated them through its preoccupation with ‘the dangers of the poorest countries being left in the dark’, which were laid out alongside appeals for more resources from the international community. Even calls for decolonization struggle to escape the shadow of one of the most intractable colonial hangovers: economic co-dependency.

A Complex Power Dynamic

A 2019 World Health Organization (WHO) report on global health financing trends found that as per-capita health spending in African countries increased over the past two decades, so did the proportion of spending that comes from external sources. In an aggregated global analysis across all low-income countries, individuals’ out-of-pocket payments accounted for the largest share of health spending, followed by donors, with governments in third place. Donors provided more than one-fifth of health spending in 20 sub-Saharan African countries, and over 40 per cent in nine. While this is often marketed as a one-way flow of charity, in reality it indicates a complex power dynamic that also yields benefits for the donor: improving its relations with the recipient country, while establishing an incentive for that country to align its policies with donor interests.

There are many demonstrations of how such alignment influences health systems in African countries, sometimes with negative consequences. A notorious example is the exclusion of condoms from US-funded HIV programs between 2003 and 2008 because, under pressure from American religious conservatives, the George W. Bush administration insisted that HIV prevention should emphasize pre-marital abstinence and post-marital faithfulness.

In the years since, country ownership has become a prominent theme in global health processes. But it is difficult to guarantee while countries are dependent on external funding for large chunks of their health budgets. Mofokeng recently called out Trump’s Global Gag Rule that has banned all health providers who receive US aid from even mentioning the word ‘abortion’—thereby restricting access to safe abortion procedures, even in countries like South Africa that have one of the world’s most liberal pro-choice policies on termination of pregnancy.

‘The dependency of African governments on foreign aid, particularly around issues of health and more specifically around sexual and reproductive health and rights, it’s shocking,’ Mofokeng says. ‘It’s shocking that without foreign aid—which often comes with unethical, or in some countries like mine, unconstitutional clauses that further marginalize people—that without that money, many health systems in Africa would collapse.’

This friction is compounded by the fact that foreign aid can also create further imbalances in health systems, due to what Power, Privilege and Priorities, a report by the research initiative, Global Health 50/50, describes as ‘global health’s lineage of colonial medicine, which focused on single diseases and did not build the systems that broadly protect and promote public health’. It is not uncommon to see massive international investment in selected areas and biomedical technologies, while the nebulous but necessary work of strengthening underlying health systems— which is our best line of defence against pandemics, as Alice Bayingana and Miriam Frisch of Rwanda’s University of Global Health Equity recently pointed out— is neglected.

‘It helps nobody to exceptionalize certain parts of human beings and decide that you’re only going to focus on those,’ Mofokeng says. ‘Part of decolonization is demanding holistic services.’ While this may sound like a simple ask, it is at odds with a global health system that has been built around disease-specific biomedical commodities—access to which raises further tensions between the right to health and the vested interests of some donor countries in safeguarding pharmaceutical industry profits.

Patients vs Profits

International intellectual property treaties grant pharmaceutical companies time-limited monopolies (patents) over the products that they have developed, which typically drives up prices. But they also provide flexibilities for public health emergencies, broadly known as TRIPS flexibilities. These include the use of compulsory licenses that allow countries to disregard patents, and either manufacture or import generic versions of medical products that are needed for emergency responses.

COVID-19 has prompted a new wave of interest in compulsory licenses from multiple countries including Chile, Germany, Israel and Canada. Based on past experience, readiness to use TRIPS flexibilities to secure affordable access to new technologies could well be a matter of life and death. Yet, in the years since these flexibilities were used, African countries have made limited use of them, which is partly due to legal complexities and health systems constraints, but has also been attributed to political pressure.

Since the early days of negotiations, countries like the United States (where pharmaceutical companies spend more than any other industry on lobbying efforts) raised political hurdles to TRIPS flexibilities. A review of the decade that followed the Doha Declaration found that most instances of compulsory licensing had been in upper middle-income countries. The review’s authors suggested that one of the reasons for this could be the greater economic weight of these countries, which enabled them to better withstand political pressure and threats of retaliatory action.

While there have since been more instances of compulsory licensing in African countries, mostly for HIV medicines, that concern still holds. In 2016, a United Nations high-level panel on access to medicines warned that governments may forgo the use of flexibilities due to ‘undue political and economic pressure from states and corporations, both express and implied, [which] undermines the efforts of states to meet their human rights and public health obligations’.

Two years later, at the first UN high level meeting on tuberculosis, this pressure was on full display through the US’ protracted resistance to the inclusion of TRIPS flexibilities in the political agreement that was to be signed at the meeting. ‘The disruptive involvement and hard-line stance of the US government in these multilateral negotiations’, wrote Khairunisa Suleiman and Suraj Madoori, ‘is part of a larger pattern in which the US prioritizes industry profits over matters of public health’. More recently, similar concerns have been flagged around COVID-19: the global agreements that would govern access to a vaccine when it becomes available, Achal Prabhala and Kate Elder warn, are ‘failing to tackle both rich country nationalism and pharmaceutical industry greed’.

This greed is particularly striking in light of the reliance of pharmaceutical research on black bodies—creating a culture of exploitation that was exposed in the suggestion by French scientists that Africa could be an experimental playground for COVID-19 new technologies, which provoked backlash across the world. ‘A lot of biomedical advancements were done on the backs of black people’s labour and scholarship, tests and research were done on the bodies of black people’, says Mofokeng.

Yet, they are often left fighting for the right to access these advancements—let alone profit off them. Recalling the press conference by Stella Immanuel, a US-based Nigerian doctor who recently declared that she has established an effective cure for COVID-19, Mofokeng remarks that the row of white men standing behind Immanuel was the first indication that her claims were dubious. ‘Where in the history of the world have you ever had white people stand behind a black woman who has found a groundbreaking potentially billion-dollar industry, and they say yes princess, you are the brains and you are going to shine for all of us? Never.’

Power, Privilege and Priorities’

According to the Power, Privilege and Priorities report, 85 per cent of global health organizations are headquartered in Europe and North America, and nationals of high-income countries constitute over 80 per cent of these organizations’ leadership. In what Canadian academic, Madhukar Pai, has described as ‘global health consulting malpractice’, expat experts can be under-experienced relative to the Africans whom they are dispatched to advise or supervise. Further, they likely benefit from the frequent salary discrepancies between ‘international’ and local employees in the development sector, which entrench inequality within the very structures that purport to be tackling it. The report warns that even as priorities and approaches have evolved over recent decades, global health continues to take on ‘ideas powered by the economic interests of former colonial powers’.

‘People go to DC and New York to design, then come here with taglines and hashtags and think miraculously people lives will improve,’ says Mofokeng. ‘They won’t improve, because you are a saviour and your worldview is not intersectional in any manner. You have no lived experience of what you are talking about [… ] it’s an industry. And so how can you tell them to decolonize when they’re executive directors of all of these organizations?’

Mofokeng, who has run independent health services for under-serviced communities for over a decade, often comes up against the reluctance of funders to invest directly in grassroots organizers, preferring instead to channel funds via North American or European institutions. ‘Why can’t funders fund women directly in Africa? Why don’t they trust us with that money for our lives? We’ve been surviving this long because we are smart.’

As Kenyan writer and political analyst, Nanjala Nyabola, has explained, public health narratives historically painted Africans as hapless and helpless, although the opposite is in fact true. Such narratives began with the dismissal of indigenous health knowledge during colonial times, which has continued to this day—despite that knowledge sometimes being the target of medical biopiracy by pharmaceutical companies who seek to secure commercial patents on traditional remedies.

According to Mofokeng, the failure of mainstream medicine to take into account the full range of knowledge and types of learning is an act of erasure and a critical design flaw in countries where large proportions of the population consult a traditional healer before turning to Western medicine. ‘Generally speaking, black knowledge and black scholarship is erased and belittled. By the time you come to healthcare and the medical systems, all those prejudices only get heightened’, she says. ‘African indigenous health systems are important. Part of the vision is integration. You need to be able to seamlessly move between indigenous health systems and the western type of secondary, tertiary, quaternary care.’

Respecting African Agency

This vision of integration challenges the notion of an inherent conflict between ‘Western’ and African medicine, instead respecting the agency and capability of African health systems across a range of medical approaches—including in the dominant medical arena, where expertise is erroneously assumed to be concentrated outside the continent. Some of the most ground-breaking research and innovations in healthcare delivery have come from African countries, although barriers to publishing in scientific journals often hinder visibility. The past decade has seen an increase in Africa-based health and science institutions, with the amount of published research from African authors growing faster than any other region. But many of these efforts still rely on foreign donors, and scientists struggle to secure financing even for potentially high-impact medical discoveries.

External investment in African health systems and research is not inherently bad. Nor do the problems in global health exist purely as a result of such investments: rather, they are rooted in a long history of oppression. ‘This history means that black people, it doesn’t matter where in the world, are more likely to experience negative health outcomes,’ says Mofokeng. ‘Just like with police brutality.’ It is precisely because of that fraught history that the ‘anti-colonial, anti-racist, and non-exploitative’ global health system that decolonization advocates have called for will be difficult to realize as long as African countries remain in the grip of a dependency whose philanthropic varnish obscures deeper reckoning with its political complexities.

‘A dangerous myth has been cloaked around the young body of global health. It is a myth that hides uncomfortable truths about inequalities of power,’ declared The Lancet editor-in-chief, Richard Horton, in a 2018 commentary on Frantz Fanon and the origins of global health. Fanon, a revolutionary Black thinker whose writings were seminal in early struggles for decolonization, was also a physician. His analysis of how medicine was co-opted as a tool for colonial control, writes Horton, and his prediction of the betrayals ahead in post-colonial worlds, offer a valuable foundation from which to understand and reconfigure global health. From an African perspective, this in turn requires tackling the insidious economic dependency of which Fanon warned.

A Political Choice

More intra-continental cooperation is one of the keys to achieving this , and has been seen in various initiatives such as the African Partnership to Accelerate COVID-19 enable African countries to negotiate imports as a bloc, giving them more bargaining power. Cooperation is a step in the right direction, but its long-term success will require significant injections of resources from African countries to strengthen their own biomedical manufacturing and health systems.

This comes with its own set of complications. The notion that most African countries are ‘poor’—itself a knotty construct— does not alone explain the disproportionate role of donors in health systems. Across the world, it has been seen that governments do not necessarily spend more on health as their countries transition to higher income brackets. ‘Relying on public funds to finance health is largely a political choice’, emphasizes the WHO in its report on health financing trends.

Mofokeng echoes this view. ‘The money [to fund health systems] is there’, she insists, but in many countries is lost to misappropriation, poor administration and wasteful expenditure. ‘They must just stop buying useless things like BMWs and being corrupt’. The concerns that have been raised regarding misuse of emergency COVID-19 funding in multiple countries across the continent illustrate this. ‘Our governments make it difficult’, says Mofokeng. ‘They themselves are the ones creating this system where we have to be dependent on aid.’

Dependency, especially in the form of debt to international institutions, also diminishes governments’ autonomy over their spending. In addition to placing a direct pull on domestic resources through debt servicing, it can compel governments to undertake broader economic reforms that negatively impact healthcare. Over the past few decades, countries seeking support from the World Bank and the International Monetary Fund have often been obliged to implement structural adjustment programmes. These programmes restrict public sector spending, making it difficult for governments to invest in foundational health systems infrastructure. They also encourage user fees and deregulation of the private sector. A 2017 review of multiple studies on structural adjustment programs came to the conclusion that they ‘undermine access to quality and affordable healthcare, and adversely impact upon social determinants of health, such as income and food availability’. As African countries take on even more debt in an attempt to weather the economic blows of COVID-19, this may in turn deepen the vulnerability of health systems to the questionable policy impositions of international financing institutions. ‘How can we decolonize as individuals in one specialty, yet our government is taking all of this money with all of these clauses that further entrench our dependency on aid?’ asks Mofokeng.

While territorial colonialism may have ended, states The Lancet in its call for decolonization, ‘this contemporary global health crisis can serve as a reminder that the colonization of medicine, economics, and of politics, remains alive.’ In so doing, it also highlights the entanglement of multiple systems that govern daily realities, such as access to medicines at the local clinic. It reminds us that getting these systems to work for Africans—not only in the continent, but across the diaspora—will not happen through incremental negotiations in silos. ‘Whether you are in economics or marine biology, the idea is that everyone must be focused on justice in every sphere,’ says Mofokeng.

Ultimately, decolonization of global health is not just about reforming this particular sector: it is contingent on the audacious hope of a deeper, wider disruption of the global axis of power

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