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.