The coloniality of global health

The full recognition of the neocolonial structure of international economic and global health relations demands much more radical political alternatives.

Freetown, Sierra Leone. Image credit Simon Davis for the UK Department for International Development via Flickr CC BY 3.0.

With the acute phase of the COVID-19 pandemic in Africa now officially declared over, the moment is ripe to take stock of what the myriad contested truths around the public health emergency have revealed about medical interventions on the continent. New emergencies and crises—such as antimicrobial resistance (AMR)—continue to generate panic, forming part of global health’s discursive African tragedy: “the uncritical epistemic industry that has long produced knowledge of African development as a monolithic and primordial tragedy.” This narrative ignores the decades of neoliberal deregulation which left many African healthcare systems under-resourced. Meanwhile, Africa itself serves as a source for raw material for medicines and the extraction of medical knowledge for the global North. These dynamics are important but they form only part of the multiple stories that need telling in pursuit of African health justice.

The COVID-19 pandemic and the AIDS pandemic that came before it made clear that medical knowledge and access to treatments play out unevenly in a world marred by deep and ongoing colonial legacies. For Africa, this has meant being positioned as the passive recipient of aid and intervention. And yet, a wealth of knowledge, resources, and technologies were—and continue to be—extracted from the continent. The idea of Africa’s supposed epistemic lack was critical for those agents justifying colonial medical interventions which spanned from social engineering to ecological experimentation to human subjects research.

Historian Helen Tilley documents the broad effects of colonial science on human health, beginning with the devastation of colonial conquest itself. To defeat the formidable Wahehe in East Africa, for instance, Germany employed a scorched earth policy to create genocidal famines and plagues. Impoverishment and trauma reverberated from the genocide of 1895-1898, as did a collective distrust for the government lasting “until tomorrow” (mpaka kesho) as the Swahili aphorism goes. Furthermore, to the extent that colonizers built healthcare infrastructure, their goal was to maximize labor power and the extraction of wealth. This meant investing as little as possible in healthcare and focusing only on diseases that impacted production. Similarly, in today’s neocolonial era of privatized global health, basic medical supplies like pain medicine and treatments for rarer conditions like leprosy continue to lack funding.

Meanwhile, colonial regimes subjected Africans to medical experimentation without their informed consent. They often coerced or manipulated African subjects into extremely painful and debilitating procedures, like the ones carried out to cure sleeping sickness. The idea of Africa as a site for the extraction of raw health data is ongoing in the twenty-first century—with pharmaceutical companies like Pfizer performing fatal meningitis clinical trials without informed consent and African blood samples being used to develop for-profit Ebola vaccines for the global North. During the recent COVID-19 pandemic, we saw this logic play out when French doctors infamously suggested that vaccines should be tested first on African populations because there were supposedly “no masks, no treatment or intensive care” on the continent. They further compared their proposed exploitation of this structural vulnerability to studies done on “prostitutes” who were perceived as ideal guinea pigs during the AIDS era. Against this backdrop of misogynoir—sexist, antiblack racism—opting out of medical treatment can be a form of protest against biomedicine’s failure of moral legitimacy in Africa.

Concomitant with these iatrogenic effects, neo/colonial global health discounts African knowledge around health and healing. Western Enlightenment and its rhetorical invention of “Africa” was founded upon a hierarchical, racialized construction of the human. These hierarchies dubbed African knowledges as “traditional,” “intuitive,” “practical,” “sensuous,” and “superstitious,”—but always outside the paradigmatic banner of the scientific. As Clapperton Chakanetsa Mavhunga writes about colonial tsetse fly control policies, the “‘natives’ became samples, specimens, data, and, at best, informants, rather than intellectual agents in their own right.” Colonizers outlawed African healers—who were often at the forefront of anti-colonial struggles—or stripped them of their powerful political influence through the epistemic purification of spirituality, which included separating “witchcraft” practices from herbal remedies.

In the coloniality of today’s global health and the system of racial capitalism in which it is embedded, the global North continuously depicts Africa as a “black hole”: a continent cast in epistemic darkness, harboring biological threats that might engulf the word, but incapable of producing truths or knowledge of global significance. For instance, while western media ridiculed and discredited Artemisia, Madagascar’s remedy for COVID-19, Europe and the USA conducted clinical trials to extract—and patent—a treatment derived from the very same plant. This double standard stems from a white supremacist, Eurocentric, and colonial definition of what counts as science and technology. As Mavhunga insists, “the arbitrary restriction of what constitutes technology to measurable things and experiments in the built laboratory performed only by those with mastery over them constitutes not just an epistemological exclusion, but also an ontological and sociological one.”

We must approach African resistance to global health initiatives in light of this longue durée. African reappropriations of biomedicine and engagements with alternative healing are often forms of fugitive science that resist EuroAmerican epistemic violence. In the case of COVID-19, for instance, much of what appeared to be “conspiracy theories” in fact harnessed the “usefulness of suspicion” to create Black counterknowledge. This counterhegemonic knowledge denounced and refused medical “surveillance, stigmatization, and the differentiation of developing countries from developed ones along (neo)colonial fault lines.”

All of these factors figure prominently in my own research on antimicrobial resistance (AMR) in East Africa, where the World Health Organization (WHO) has told governments to establish National Action Plans for AMR. Global health experts urge African countries to make haste as AMR becomes a new “silent pandemic” now considered among the top ten global health challenges in the world. It has the highest mortality rates in sub-Saharan Africa. In Tanzania, the WHO AMR Plan’s objectives include “strengthening patient and health care provider compliance” to conform with standards of drug use developed in the global North. According to this Plan, the solution for so-called “misuse” or “overuse” of pharmaceuticals lies with promoting “behavioral change” and installing “new attitudes and practices” to be “embedded in the whole society.”

Antimicrobial resistance is surely a serious and urgent concern. But this is all the more reason to recognize and refuse the coloniality behind health interventions which assume that African doctors and patients are not well-informed. My ethnographic research demonstrates that in fact they very much are, and that practices like buying only partial dosages at a time stem not from ignorance but from structural injustices like the prevalence of counterfeit drugs.

Almost half of all detected cases of counterfeit drugs are found in Africa: “the proportion of fake pharmaceuticals in some countries can be as high as 70%.” Even the World Health Organization (WHO) emphasizes that “the greater the efforts made to look for substandard and falsified medical products, the more of them are found.” Why then do global health organizations like WHO frame their interventions in terms of “compliance” and “attitudes”? Why not aim them instead at the structural problems which force patients seeking medicinal efficacy to experiment with drugs in the first place?

If AMR does indeed threaten “the very core of modern medicine” as the WHO claims, then it needs a structural solution that brings reliable, quality, affordable pharmaceuticals to African consumers. As structural adjustment programs imposed free-market principles in Africa, multinational pharmaceutical companies fought to maintain their markets against a rise of generics. And, as African countries fought back, wealthy nations sought to interrupt movements for social medicine on the continent. They did so by offering targeted aid interventions which provided select pharmaceuticals like antibiotics and antiretrovirals—often ones they produced in their own countries. Thus, Western domestic economies benefited while African pharmaceutical industries were left underdeveloped, aid dependent, and with severe shortages of drugs. These are problems that cut to the core of the neocolonial world order. But Western media and global health initiatives misrecognize this when they gloss such issues with racially coded phrases like “ignorance,” “hygiene,” “cultural norms,” and “attitudes and behaviors.”

In the same month the COVID-19 pandemic was declared over in Africa, we also heard the United Nations Secretary-General, António Guterres, remark that Africa as a whole spends more on debt repayments than on public healthcare each year. Despite this indictment, however, the Secretary-General’s proposed solutions were predictably mild fare. They did not question the racialized and gendered capitalist world order. Activists and public intellectuals have long insisted that we must recognize the neocolonial structure of international economic and global health relations and that this recognition demands much more radical alternatives. Proposed solutions range from debt cancellation and reparations to a universal basic income and the degrowth of the global capitalist system. As international organizations move once again to reinforce inequalities that protect the global North at the expense of Africa in the name of “global health,” perhaps these radical-sounding solutions deserve a closer look.

Further Reading