
By Ramisha
Global health is generally defined as a research, practise or study which aims to improve health and reach equity for all people worldwide. However, global health is distinct from other disciplines of health science or public health dealing with health issues on a global scale [and to] utilise research systems, knowledge bases and all sectors of society towards the promotion of health worldwide. While global health can have a localised aspect, in terms of research and policymaking in an increasingly globalised world – through trade and the movement of people – has resulted in countries, non-governmental organisations and corporations showing increased interest within this discipline.
The term global health emerged in scientific literature in the 1940s and was adopted by the World Health Organisation (WHO) as a foundational principle for the UN body towards “…directing and coordinating authority on international health…”. Whilst the aims of global health on the surface are based on altruism, equality and justice within healthcare, the root of the discipline – tropical medicine – has arguably been complicit with upholding, maintaining and profiting from colonialism.
Colonialism, tropical medicine and merchant
Tropical medicine is a subdiscipline of medicine which emerged at the end of the 19th century because of European colonialism, providing a clear example of the social and political formation of Western medical knowledge. In the context of the British Empire, spanning a quarter of the landmass at its height two institutions – the London and Liverpool – schools were established and continue to be held as the forefront of the global health field.
The formalisation of tropical medicine through the creation of institutes, such as the Liverpool School of Tropical Medicine and London School of Tropical Medicine, was a colonial endeavour with the primary funding coming from colonial merchants or governments. To illustrate, the Liverpool school was founded in 1898 by the Elder Dempster shipping company whose owner made significant profits from colonial exploitation, especially during the infamously brutal King Leopold II rule of the now Democratic Republic of Congo. In comparison, the London School of Tropical Medicine (now the London School of Hygiene and Tropical Medicine) was established by Patrick Manson, who elucidated the infective agent of malaria, with the support from the Colonial Office. At both schools, colonial medical officers and practitioners would train before being placed in the colonies, working for private companies or missionaries, with the teaching specifically at the London school “not question(ing) Britian’s right to rule.”
A commonality within the London and Liverpool schools was the endorsement of Joseph Chamberlain, the Secretary of State for the Colonies, while also having an interest in malaria research, declared at the inauguration of the Liverpool school: “to fight tropical disease constitutes the [real] basis of the politics of colonisation”. These motivations are also apparent within other schools of tropical medicine within Europe with the supporters of the tropical medicine school in Lisbon sharing “the prosperity and wealth of a colony depend, first of all, on the ease of the living conditions to be found there by the colonists” with the research and study of European tropical medicine institutions “converted into colonial well-being and colonial prosperity.”
Therefore, these declarations – as well as the formalisation of the discipline through the institutions in London and Liverpool – cements tropical medicine as a discipline which allows further European colonisation, often benefitting from monetary support of private companies and the colonial state. Considering the economic and political relationships of colonialism leading to the formation of the London and Liverpool schools of tropical medicine this discipline could be understood as a cultural component of colonialism. Ultimately, this lays the foundations for the West being a hegemonic authority of science over disease in the “non-European” world.
Knowledge production is shaped by socio-political forces and considering tropical medicine as a body of knowledge within the context of the British Empire it is important to consider for whom and why research about the periphery was taking place in the metropole.
The London and Liverpool schools’ research and teachings proved essential to make the tropics safe for settlers and army officers, which were vital to imperial control. Diseases of the colonies were a huge barrier to colonial expansion, especially within Africa where malaria, yellow fever and sleeping sickness were prevalent. Areas of the continent of Africa, especially the Western coast, were dubbed the “white man’s grave”, due to the high mortality of officers and settlers in these areas. For example, some historians estimate that white mortality averaged 70 or 80 per 1000 in the late 1800s with troops in Sierra Leone between 1817-1838 averaging mortality at 500 per 1000. While reliable data is not available, a British parliamentary committee recommended the withdrawal of troops and settlers from West Africa citing it as a “hotbed of disease” outlining that this area being “unfit for occupation by the Anglo-Saxon race”. Although some report that approaches were expanded to indigenous population(s) these were done so primarily within labour groups. Therefore, considering the colonial origin of the finances leading to the establishment of the two schools in Britian it can be said that tropical medicine was conceptualised and institutionalised within the primary interest of the health of settlers and army officers.
Reports of approaches were expanded to indigenous labour groups, fitting into the rationale of colonialism being a benevolent function, but some will argue that motivations were based in the further colonisation of land and resources. Indeed, trading firms and the commerce department were the primary critics of the “West African health conditions” at the time and would complain of the “polluted ponds and wells, refuse strewn streets and yards…” to the Colonial Office1. Moreover, colonial merchants would pay money to the Liverpool school to have access to the medical knowledge highlighting that malaria and other “tropical diseases” were seen by colonial businesses and governments as major threats to the health of settlers, the profitability of the empire and an obstacle to colonisation. Therefore, some outline how the study of malaria and the formalisation of tropical medicine, through colonisation, are so tightly bound to one another that “these two legacies cannot be separated.2” Overall, this presents tropical medicine was developed in response to the high mortality rates of white settlers and army officers within the periphery and ‘tropical diseases’ was conceptualised by colonial governments and merchants as an obstacle towards further colonisation and economic extraction.
Coloniality and global health
Tropical medicine, and by extension, colonial medicine, is seen as an unfortunate remnant of a colonial era, as the current iterations of the London and Liverpool schools are clear about the colonial origins of their schools with both publishing reports into the way the institutions benefitted and established from colonialism. While this is conceptualised as efforts to ‘decolonise’ the university and by extension global health – the discipline emerging from tropical medicine – there are reports of the need for wider more systemic institutional changes or reparations rather than commentaries about the colonial past of such institutions. Thus, many academics and activists conceptualise parts of global health continuing perpetuation of (neo)colonial relationships with the “other.” These patterns of coloniality are re-established through pharmaceutical trade, research relationships and settler colonial powers.
Generalised aspects of global health are important for population health but biotechnological innovations, such as vaccines, can be instrumental in treating and at times even curing disease. For example, smallpox eradication through world-wide vaccination efforts is rightfully considered an influential lesson in what global health aims to achieve through its various spheres of influence. However, the enduring COVID-19 pandemic and the inequitable distribution of vaccines is an issue that global health institutions, including the WHO, has come under increasing scrutiny for. While considering the novel nature of the virus, once a vaccine was developed by major pharmaceuticals, “Global North” countries pre-ordered doses bypassing a collective purchase initiative that promised equitable distribution via COVID-19 Vaccine Global Access (COVAX) launched by WHO.
With a few notable exceptions, as time went on the gap of vaccination between countries widened, with nearly all countries in the continent of Africa delayed in relation to the rest of the world. For example, as of November 2022 only 25% of the total population within the continent of Africa has been fully vaccinated against COVID-19 whilst those within the “Global North” have vaccination rates between 70-80% (1,2). This inequitable, persistent gap in vaccination rates was dubbed by the WHO Director General as “vaccine apartheid”, in reference to the institutionalised South African system of racial segregation (3). While other considerations apart from vaccine availability is worth considering, such as vaccine hesitancy and weak health systems the COVAX structure itself requires critique(4,5). This alliance potentially allowed for this disparity to occur as it failed to deliver its supply forecasts, deals outside of the alliance were allowed, and strict intellectual property rights on pharmaceuticals remained unchallenged (6). The inequitable share of vaccination prolongs the pandemic with some estimating that if the COVAX vaccination target had been achieved 156,900 additional deaths would have been averted for each country (7). Further, variants of concern which arise from prolonging the pandemic, due to vaccine apartheid, can evade immunity gained from vaccination, reduce vaccine efficacy and increase transmissibility. While many consider widening provisions from the Global North to the majority “…is not only moral but also pragmatic” it fails to consider the domination the North countries apply on the development, production and distribution of vaccines to the disadvantage of the Global majority (7,8). Overall, as apartheid can be conceptualised as a function of colonialism this presents the way in which “Global North” countries undermined the COVAX initiative, while flawed at its inception, led to a “two-tier” pandemic which is an expression of enduring coloniality within global health.
The metropole was the centre of research on the colonised “other” within tropical medicine, but the current global health field highlights the importance of joint research partnerships. However, simply highlighting importance has a limited function as authorship of infectious disease research between 1980 – 2016 shows while African collaborators of studies conducted on the continent are “ubiquitous” they do not feature on lead authorship positions (9). Indeed, African researchers in first author position were majority from an Anglophone country with lead publication role being especially low for HIV and malaria research. Lead authorship is especially important in scientific publishing as they are considered to significantly contribute to the conceptualisation, design, and analysis of the publication. Therefore, this suggests most of the research during this time under-represents African researchers about research done in Africa, especially if not from an Anglophone country or within malaria and HIV topics. This potentially re-establishes a colonial pattern of knowledge production. Furthermore, this determines an establishment of parachute research agenda where researchers from the Global North visit the Global South, use local capacities, and leave to write a paper despite its unfavorability within journals.
The key issue of global health research is funding and capacity building, as of the worldwide $37 billion spending on biomedical research in 2020, a staggering 99.1% went to “high income countries” – considered to be the Global North – while much of global health research is carried out within the Global Majority. Furthermore, less than of this funding 5% went towards capacity building. Therefore, many have called for a re-balancing of power through the establishment of a Global Fund to enhance research capacity led by research of the global majority. Thus, highlighting importance alone without addressing methods of re-balancing power though inequitable research funding and capacity building may unintentionally re-establish colonial research relationships.
The coloniality within global health can be extended to internal colonialism, defined as a power structure involved in the management of people(s), land and environment within the borders of an imperial nation state. Ultimately, the settler colonial structure moves towards the elimination of the native and collapsing the divide between the colony and the metropole one which external/franchise colonialism aims to maintain. To illustrate, the occupation of Palestine and the ways in which Israel deliberately targets hospitals, blockade medicine and deny exit permits to Palestinians seeking healthcare in Gaza is a key tactic in Israel’s genocidal violence. Therefore, these actions can be conceptualised as a move towards eliminating the native. Moreover, the framing of Palestinian health as a ‘humanitarian issue’ to be solved by the global health community through aid – while well intentioned – allows Israel to not only relieve its responsibility as an occupying power but also to continue its attacks with impunity on an indigenous population seeking self-determination. Thus, settler colonialism can be considered a structural determinant of health as the occupying power shapes the socioeconomic, political and environment towards indigenous erasure and the maintenance of the settler population. It is despite the settler colonial power that Palestinian doctors through the genocidal attacks on Gaza have reaffirmed the revolutionary potential of medical practice exemplifying resistance in the face of settler-colonialism.
The way colonial ties persist though the distribution of pharmaceuticals, the production of knowledge, and the continuance of settler-colonial powers suggests a maintenance of colonialism despite efforts towards decolonisation. Therefore, this challenges the universalised notion of global health – for the good health of all – with a suggestion that the field and its outputs will be shaped by (neo)colonial global actors and what they determine global health to be. It is despite these global actors that individuals and occasionally specific nations continue to resist (neo)colonial forces for the betterment of health.
References
- Turyasingura N, James WG, Vermund SH. COVID-19 vaccine equity in Africa. Trans R Soc Trop Med Hyg. 2023 Jun 2;117(6):470–2.
- WHO. COVID-19 vaccines | WHO COVID-19 dashboard [Internet]. [cited 2024 Dec 3]. Available from: https://data.who.int/dashboards/covid19/vaccines
- Bajaj SS, Maki L, Stanford FC. Vaccine apartheid: global cooperation and equity. The Lancet [Internet]. 2022 Feb 23 [cited 2022 Mar 30];0(0). Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00328-2/fulltext
- Hunter DJ, Abdool Karim SS, Baden LR, Farrar JJ, Hamel MB, Longo DL, et al. Addressing Vaccine Inequity — Covid-19 Vaccines as a Global Public Good. New England Journal of Medicine. 2022 Mar 24;386(12):1176–9.
- Usher AD. A beautiful idea: how COVAX has fallen short. Lancet. 2021;397(10292):2322–5.
- Pushkaran A, Chattu VK, Narayanan P. A critical analysis of COVAX alliance and corresponding global health governance and policy issues: a scoping review. BMJ Glob Health. 2023 Oct 4;8(10):e012168.
- The global impact of disproportionate vaccination coverage on COVID-19 mortality – The Lancet Infectious Diseases [Internet]. [cited 2024 Dec 3]. Available from: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00417-0/fulltext
- Seretis SA, Mavroudeas SD, Aksu Tanık F, Benos A, Kondilis E. COVID-19 Pandemic and Vaccine Imperialism. Review of Radical Political Economics. 2024 Oct 23;04866134241282107.
- Mbaye R, Gebeyehu R, Hossmann S, Mbarga N, Bih-Neh E, Eteki L, et al. Who is telling the story? A systematic review of authorship for infectious disease research conducted in Africa, 1980–2016. BMJ Global Health. 2019 Oct 1;4(5):e001855.