The COVID-19 pandemic has brought renewed attention to health system inequities that exist not only in our own country but around the globe. This heightened awareness has led many to question why such injustices in health care exist and how such global health governance structures came to be. Professor Rafael Pérez-Escamilla, director of the Yale School of Public Health’s Global Health Concentration, recently discussed global health outcomes and the harmful legacy of neocolonialism with YSPH Associate Dean for Diversity, Equity and Inclusion and Associate Professor of Epidemiology (Chronic Diseases) Mayur Desai. Pérez-Escamilla shares not only his scholarship on global health and neocolonialism having worked in more than 20 countries across all regions of the world, he also brings a first-hand perspective of health system inequity having grown up in Mexico, one of the most inequitable countries in the world.
MD: How do you define global health?
RP-E: Global health is the area of public health concerned with the spread of disease across countries and world regions. Global health problems can concentrate in just a few countries or extend globally as we’ve seen with pandemics such as COVID-19; HIV; obesity and related noncommunicable diseases such heart disease, diabetes and some cancers; and the mental health crisis. Interestingly, before the term “global health” started to be used more commonly, the term used for decades was “international health,” reflecting a patronizing concept whereby high-income, powerful nations help low-income countries deal with their public health problems because they are incapable of doing so by themselves. This concept was a direct legacy of colonialism and its profoundly racist attitudes.
It is undeniable that racism was behind the justification for the extraordinarily painful cultural genocides that colonizers inflicted on local populations and the way they took over their lands and resources, that resulted in major historical trauma and negative public health consequences to this day. And you don’t need to take my word for it, just look at the current health statistics for Native Americans in the United States, or indigenous communities in Mexico, or the aboriginal people in Australia and New Zealand, or the people from the Marshall Islands where the United States tested nuclear weapons, or the people of Vieques, Puerto Rico, used by the US as a bombing range for six decades against the will of the population in spite of strong evidence that it was harming their health and the environment.
MD: What do you mean by neocolonialism and why does it matter for global health?
RP-E: The neocolonialist approach is rooted in a legacy of the strongly unjust social, political and economic systems established since colonial times. As such, the neocolonialist approach to public health assumes that less economically developed nations have health problems that only White men from economically advanced powerful nations know how to solve. Furthermore, it assumes that lower income nations do not have cultural or social assets of value and that they are inhabited by ignorant and uncivilized people. In other words, it is based on White saviorism, and hence neocolonialism is also intrinsically racist. The neocolonialist approach in public health has four major characteristics: 1) Imposes top-down solutions without consultation with local communities; 2) Strongly emphasizes biomedical “magic bullet” solutions to public health problems without paying much attention to the social determinants of health (SDOH) and human rights; e.g., health care, food, education, shelter and sanitation; 3) Improves the health of the population to more efficiently exploit and profit from their labor; 4) Seeks to wins hearts and minds through health interventions to gain undue political and economic influence.
MD: How do global health governance systems work? Who runs them?
RP-E: For more than 100 years, the global health system has been governed through a powerful alliance of multilateral financing and development assistance organizations (e.g., World Bank, International Monetary Fund), international health organizations (e.g., WHO, UNICEF), private foundations (e.g., Rockefeller Foundation, Bill & Melinda Gates Foundation); bilateral government foreign aid agencies (e.g., USAID), and of course, the private sector; especially the pharma industry.
Even though until recently this alliance functioned through a neocolonial lens, the good news is that at least in principle, financing and global health organizations now fully acknowledge that the SDOH and equity are the final solution to addressing the global health crisis. Also, we now have examples of successful anti-neocolonial South to South cooperation (i.e. global health partnerships established and led by lower income countries) including the production of affordable generic drugs in lower income countries led by Brazil, human milk bank networks (also led by Brazil) and anti-obesity policies in Latin America including taxes on sugar-sweetened beverages and junk food, warning labels on packaging and protection of children against marketing of junk food against sugar-sweetened beverages in spite of strong opposition and lobbying from the food industry.
The neocolonialist approach to public health assumes that less economically developed nations have health problems that only White men from economically advanced powerful nations know how to solve.
Rafael Pérez-Escamilla
MD: How can academic institutions help change the status quo?
RP-E: The powerful global health governance alliance in place for over a century established strong partnerships with and funded prestigious U.S. and European schools of public health. As a result, these schools became the places where the most influential public health professionals, including those from less economically developed countries, were trained through a strong neocolonial lens; i.e., biomedical solutions that strongly ignored the SDOH. In my view, even though we are at a better place now, the way schools of public health continue to train students is not changing fast enough to help form the future leaders who can transform the guiding principles and architecture of the current global health system.
At the end of the day, I believe that curricular reform is needed to strongly instill and train global health students through practice-based learning approaches on: 1) SDOH and equity; 2) Bioethics; 3) Community-based participatory research (in context of cultural humility); 4)Antiracism frameworks and how to operationalize them; 5) Implementation of science/practice embedded in team and citizen’s science systems thinking; 6) Evidence-based advocacy to help redesign the strongly unjust global health and economic systems running our world these days. This is crucial because neocolonialism and neoliberal or trickle-down economics thinking go hand-in-hand and they have clearly been a catastrophe for public health and the health of our planet.
MD: Are there readings that you recommend?
RP-E: There are four reading that I strongly recommend: 1) “A History of Global Health” by Randall Packard, 2) “Colonial Pathologies” by Warwick Anderson, 3) “Panama Fever” by Matthew Parker, 4) “A History of Public Health” by George Rosen, and 5) “Household food insecurity in black-slaves descendant communities in Brazil: has the legacy of slavery truly ended?” by Muriel Gubert and Rafael Pérez-Escamilla.