Offline: The case for global health

Abstract

Global health has become fashionably unfashionable. The case against global health is strong. Global health is the invention of a largely white and wealthy elite residing in high-income, English-language speaking countries. The discipline claims to be concerned about the health of people living in low-income and middle-income settings. But the resources—human, infrastructural, and financial—underpinning global health are mostly concentrated in those countries already replete with power and money. “Helicopter” research is not uncommon. The contribution of scientists and research funders to sustainable advances in health care in the countries of their alleged concern is minimal. More often, the relationship between western medical science and the countries they work in is extractive. Global health institutions are mostly led by western-educated men. Global health agencies are only superficially member-state organisations. In truth, influence lies with those nations providing the greatest resources. Global health has enabled public health schools and university departments to continue to enrich themselves through exorbitant student fees and generous research grants. Global health journals are no better. Most are creatures of western medical publishing houses, even those that proclaim radical open access histories. The unearned privileges of a few suppress the justified demands of the many. It is hard to avoid the conclusion that global health is little more than an exclusive club, disguising its colonial origins and practices in the stirring language of equity and justice. The view that global health is a colonial project underlies the call for decolonisation. As Franziska Hommes and colleagues wrote in The Lancet Global Health in 2021, the goal of decolonisation must be “to critically reflect on [global health's] history, identify hierarchies and culturally Eurocentric conceptions, and overcome the global inequities that such structures perpetuate”. The democratic promise of global health to be an inclusive enterprise has been broken. Some critics argue that global health can never solve inequity. Some go further and suggest that global health is structurally racist. It is hard to disagree with these conclusions. Although global health journals might mean well, the operation of waiver policies for article processing charges has created a culture of humiliation for scientists who cannot afford western journal open access fees. Journals have worsened Northern ventriloquism, where scientists from lower-income settings feel forced to adhere to high-income norms and standards to be permitted to publish in their pages. In Global Health in Practice, Olusoji Adeyi offers a compelling analysis of how imperialism and colonialism became the “founding pillars” of global health. And his observation that “The din of protest against colonialism in global health is getting louder and it has merit” should provoke those of us who work in global health to pause. For Adeyi is surely right that “the Global North decides the narrative and assumes the omniscience to tell the Global South what the latter needs, when it can have it, how to do it, and on whose terms it must be done”. When I was a medical student, I remember those attached to various causes arguing with passion among and against ourselves, viewing one part of our group as betraying the real truth that we were seeking to defend. Those on the progressive wing of politics are supremely good at introspective annihilation. And that same process of internal obliteration is now unfolding in global health. While we identify enemies among ourselves, we miss the larger story of just who our opponents really are—those trying to destroy the conditions for achieving the right to health, equity, liberty, and social justice. For the real enemies of the values we stand for do not sit within the ranks of global health. They are to be found in governments that instinctively mistrust—and who wish to undermine and defund—global organisations. They will be found among those who demonise refugees. They are the climate sceptics, anti-vaxxers, and purveyors of scientific misinformation. They are those who attack the redistribution of wealth, those who believe that war brings peace, and those who defend racism under the guise of patriotism. Global health practitioners should certainly engage in robust discussions about the meaning of their discipline. But they should be clear about who our struggle is really against. It is not global health. Instead, we must work harder together to create a new political frontier and forge a new collective against the true enemies of health.