As the COVID-19 pandemic undermines health systems globally, it has disproportionately affected Black, Indigenous, People of Color (BIPOC) and other marginalised communities. To address health inequities perpetuated by structural racism and Eurocentric knowledge systems built on colonial medicine, calls to decolonise global health are gaining traction.

On 18 November 2020, a session of the Geneva Health Forum brought together a panel of representatives from global health journals, NGOs, and academia for an urgent discussion of concrete steps to reform global health governance. The speakers included Seye Abimbola, Editor of BMJ Global Health; Tammam Aloudat, Senior Strategic Advisor of the Access Campaign at Médecins Sans Frontières; Emanuele Capobianco, Director for Health and Care at the International Federation of Red Cross and Red Crescent Societies; and Sarah Hawkes, Director of the Centre for Gender and Global Health and co-founder of Global Health 50/50.

Global health, as we know it today, remains far from its goals of equity and justice. Western perspectives, knowledge and power have been dominating the global heath arena through academic journals, educational institutions, as well as the locations of NGO headquarters and conferences (such as the Geneva Health Forum). The Global Health 50/50 initiative found that only 17% of leaders of global health organisations come from low and middle-income countries (LMICs), while 50% are from the US and UK. Strikingly, 8% received degrees from Harvard, the same percentage as degrees from all LMIC schools combined.

“Bill Gates can publish an editorial in the Lancet, the BMJ, the New England Journal of Medicine, or the New York Times within five minutes about any topic in global health of his choosing. Very few people in the Global South, no matter their skills, decades of expertise or lived experience can dream of doing the same. These are comically obvious issues that need to change,” commented Aloudat during the Geneva Health Forum.

Decolonisation demands freedom from domination, as well as achieving educational, economic, and cultural independence. Abimbola called for clarity as the first step: “There is a lot of discussion about what is wrong with the system, but we’re not yet clear about what a decolonised landscape of global health looks like.” Aloudat suggested moving from an exclusively benevolent definition of global health towards one that considers existing power dynamics. Rarely has a colonial power in history given up its position of power voluntarily, and it comes as no surprise that those in power are not willing to let go of it. To advocate for reform within a complex field of stakeholders and opponents, Hawkes offered lessons from feminist activism in the corporate sector. Organisations are often not motivated by calls for social justice, or righting historical wrongs, but by calls for effectiveness. Activists have demonstrated that a lack of diversity, not just in leadership but throughout the workforce, is ineffective.

Redistribution of power in global health must happen at both individual and systemic levels. Hawkes advocated for systemic change, because “putting a woman in charge does not lead to a feminist system. Feminist and decolonised systems are not led by single individuals, they are led from the bottom up.” Aloudat also argued for holding leaders accountable, since they are often descriptors of the system and hold keys to its change. However, the fight for equity is by no means a zero-sum game. Neither are global health needs nor the ability to expand interventions finite. There is plenty of work for everybody to contribute in a democratic way, Aloudat emphasised.

As for actions organisations can take moving forward, Abimbola asked major global health journals to commit to strengthening alternative platforms for knowledge exchange that are closer to the ground, where global health actually happens. What concrete steps would it take for the LSHTM, the Lancet, the BMJ, or any other central entity to turn themselves into peripheral players? Does it mean, for instance, that the London School needs to de-emphasise itself, to redirect its funding, or to decentralise its training and move to locations around the world? An imagination of concrete steps is necessary for any productive discussion about decolonising global health.

Aloudat called for global health organisations to move decision-making away from headquarters sitting in explicitly ex-colonial powers. This can happen by physically moving, or by insistently achieving more diverse representation at every level of leadership without falling into checkbox tokenism. A paradigm shift in the workplace also requires dismantling structural racism and predominant cultures that assume certain staff as less competent. “The four of us on this panel are from a single school,” said Aloudat as he highlighted the glorification of elite degrees such as the one from LSHTM. Obvious barriers such as high fees and required relocation to London contribute to disparities in access to global health education.

To broaden the conversation, Hawkes pointed out that the global health system does not exist alone: “It exists within an incredibly imperialist economic system, and until we tackle that system, we will not right historical injustices. We must think very broadly and politically about what determines health for everybody.” For global health to overcome its colonial past and truly improve well-being for all, stakeholders must define clear problems and take concrete steps to redistribute funding, knowledge, authority, leadership, and decision-making power among communities. It will take significant commitment to imagine a global health system unrecognisable from the one we see today. That work is absolutely necessary to create a better future for our collective well-being.

Written by Grace Jin, student in Development Studies (MDEV) at the Graduate Institute, Geneva