The growing calls to decolonise global health

Comment
www.thelancet.com/lancetgh Vol 9 October 2021 e1359
Why and for whom are we decolonising global health?
The growing calls to decolonise global health are
welcome but also worrisome. Suggestions for
decolonisation vary greatly, with a common view
to shift power to local ownership but without clear
plans on how to make this suggestion a reality. Many
researchers are calling for global health research to be
led by local leaders in low-income and middle-income
countries (LMICs), with expatriate academics providing
peripheral support rather than the other way around.1
Others call for radical transformation as the only
reasonable response to addressing the complexity of
reforming global health research when many leaders in
global health have built their careers in institutions that
advance and sustain white supremacy.2,3
Global health institutions, researchers, and priorities
are predominantly in high-income countries (HICs),
whereas the bulk of the research work and intervention
programmes are implemented in LMICs. Commendable
gains have been made in addressing global health
issues, such as treatment for people living with HIV, but
wholesome improvement of the health-care system of
LMICs is often minimal or non-existent, highlighting
the priorities of HICs and dependency on donor
programmes. The push to decolonise global health and
the resultant conversations are, unsurprisingly, taking
place primarily among academics based in HICs, and
LMIC participation is limited to researchers who have
built their careers within the current colonial global
health structure. Perhaps there is something to learn
from the process of political decolonisation in countries
like Kenya. Colonial powers, facing the inevitability of
granting independence to colonies, were intentional in
leaving power in the hands of local leaders sympathetic
to the European outlook: western-educated descendants
of paramount chiefs appointed and propped up by the
colonial regime in largely acephalous communities, or
people in LMICs who had converted to Christianity and
had an education—factors which often were conjoined.
These colonially appointed and backed local leaders were
also the beneficiaries of the Africanisation of the colonial
civil service. In political decolonisation, leaders in LMICs
have sustained the same political and socioeconomic
structures carved by colonial governments, resulting in a
relationship of dependence, neocolonialism, and an everwidening gap between the rich and the poor. Akin to this
transition in political leadership, dominant global health
institutions, through education and leadership positions,
have produced researchers educated to HIC standards
from LMICs who are replete with skills to work within
the current global health system, sustaining their power
structures in the process. The call to diversify global health
leadership, if done within the current structures, runs the
risk of repeating the same decolonising mistakes.
Even if global health research priorities were set
by academics in LMICs, closer examination of the
relationship between global health researchers from
HICs and those from LMICs shows the situation to be
direr: research grants for projects in LMICs are channelled
through researchers and institutions in HICs; researchers
in LMICs have not had the resources at the disposal
of their counterparts in HICs, such as protected time,
grant teams, advanced laboratory infrastructure, and
postgraduate trainees from around the world to work
with. Asking leaders from LMICs to take up positions
within the current structures without acknowledging the
entire systems made to support careers of researchers in
HICs would be but a cosmetic change. True transfer of
power and equitable partnerships will require investing
as much time into rebuilding research infrastructure
from the ground up in LMICs as is done in supporting
individual careers of global health researchers in LMICs.
Similarly, we need to pause and ask whether
ordinary citizens in LMICs, struggling under a system
bearing colonial legacy in multiple spheres of their
lives, are participants in this discourse, and whether
their participation in challenging this system can be
through “rational confrontation of points of view”4
in
journals based in HICs. The ordinary citizen will probably
prioritise comprehensive health care—a stark contrast
to the long history of studying tropical diseases. When
goals of local global health researchers uphold those
of researchers in HICs, will diversifying global health
leadership address the plight of citizens in LMICs? The
fragile health-care system in LMICs is a simple proxy for
equity and justice in global health.
Lastly, decolonising global health cannot be complete
without examining the socioeconomic and political
context. The structure and objectives of research and
collaborations in global health must be decolonised to
address the whole spectrum of health determinants.
Comment
e1360 www.thelancet.com/lancetgh Vol 9 October 2021
We declare no competing interests.
Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY-NC-ND 4.0 license.
*Ong’era F Mogaka, Jenell Stewart, Elizabeth Bukusi
[email protected]
Kenya Medical Research Institute, Nairobi 54840-00200, Kenya (OFM, EB);
Department of Global Health (JS, EB) and Department of Medicine, Division of
Allergy and Infectious Diseases (JS), University of Washington, Seattle, WA, USA
1 Costello A, Zumla A. Moving to research partnerships in developing
countries. BMJ 2000; 321: 827–29.
2 Hirsch LA. Is it possible to decolonise global health institutions? Lancet
2021; 397: 189–90.
3 Abimbola S, Pai M. Will global health survive its decolonisation? Lancet
2020; 396: 1627–28.
4 Fanon F. The Wretched of the Earth. London: Penguin Classics, 2001: 31.