The WHO Collaborating Centre on Global Health Histories, which is supported by the Wellcome Trust, has produced a series of seminars in association with the WHO HQ, WHO Regional Offices, WHO Country Offices and national governments, which bring together panellists from diverse backgrounds to discuss and debate topical issues in global health, based on a deeply inter-disciplinary examination of the recent past.
This briefing is based on presentations at three seminars which look at the cultural context of ‘global health’ and at work that is being carried out to decolonise this area.
The seminars can be viewed and/or listened to here:
Global Health Histories Seminar 120: History, Culture and Global Health Sustainability
(Cultural and Health webinar)* 14 March 2019, Cambridge, UK
Speaker(s): Dr Nils Fietje (WHO Regional Office for Europe) and Dr John Manton (London School of Hygiene & Tropical Medicine)
Moderators: Dr Aliko Ahmed (Associate, Hughes Hall & Director PHE, East of England) & Dr Arthur Hibble (Senior Member and Tutor, Hughes Hall, University of Cambridge)
Global Health Histories Seminar 140: Decolonizing Global health - Theories, Methods, Language
31 January 2020, Duke University, US
Speaker(s): Dr Kearsley Stewart (Duke University), Professor Walter Mignolo (Duke University), Amy Locklear Hertel (UNC Chapel Hill), Professor Madhukar Pai (McGill University), Dr Meleckidzedeck Khayesi (WHO)
Global Health Histories Seminar 141: Global Health Futures
31 January 2020, Duke University, US
Speaker(s): Laura Mkumba (Duke University), Dr Eugene Richardson (Harvard Medical School), Professor Deborah Jenson (Duke University), Professor Sanjoy Bhattacharya (University of York), Dr Allysha Maragh-Bass (Duke Global Health Institute), Dr Seye Abimbola (University of Sydney)
“Decisions are rarely based on fact alone; they often draw on emotions and we need to understand the cultural contexts of these emotions,” says Dr Nils Fietje, who is a research officer at the World Health Organization (WHO) Regional Office for Europe where he leads a project on the Cultural Contexts of Health and Well-being (CCH).
Health history, as much as any other area of history, is not one dominant narrative; and the official narratives are partial, leaving out much of what has actually been done in different countries. The University of York’s Centre for Global Health Histories is addressing this, with the seminars in particular highlighting areas where some of the expectations of healthcare have proved harder to resolve than the people initiating them might initially have thought. The priorities people bring to polio; the different perceptions of Ebola; the reasons why people may refuse treatment, or insist on using antibiotics – these are all the result of different factors. A narrative which thinks of health as ‘delivered’, by broadly Western or Western-directed actors, to passive and/or ignorant recipients is not just ineffective – it is counterproductive, and it is inequitable. It ignores the people who are making decisions about their own health from within their own cultures and constraints. If the drive towards better health worldwide is to succeed, we need to look at health in its full context.
The meaning of ‘culture’
The term ‘culture’ itself is pretty loose, Fietje fully acknowledges. “Ultimately, I think we all understand that it relates to practices, beliefs and values. We’re trying to make more people and practitioners aware that culture is also dynamic, not monolithic. It’s not just a question of race or geography, it’s something that we all have even if it’s just two people sitting down talking to each other. The CCH project is looking to give a platform to culture.”
Investigating the cultural contexts of antibiotic resistance, for instance, counters the idea that the solution to this crisis is purely medical. Instead, it turns attention to the wide variety of social and commercial and cultural drivers that influence the use of antibiotics. These are all crucial factors to address if the crisis of antibiotic resistance – which the WHO has put on a level equivalent to that of climate change – is to be brought under control.
“Cultural practices also have positive values, and tapping into those positive values can help us promote health,” Fietje adds. Some of the ways in which people in Ebola-affected areas traditionally deal with the disease, for instance are completely in line with ways of thinking about social distancing and isolation (with which people in the UK and US have notably struggled during the COVID-19 pandemic). The beliefs that people have and the things that they do – that we all do – are part of how we construct our lives.
The term ‘global health’
Inevitably, culture, context, assumptions and all the associated issues contribute to how the term ‘global health’ is also perceived. It is not a neutral term, point out several people who are centrally involved in the field. Context is crucial.
Dr Madhukar Pai is based at McGill University in Montreal, Canada, where he is the director of McGill Global Health Programs and the McGill International TB Centre. “I have seen the world of global health – whatever it is – from both sides,” he says. “For 30 years, I lived and worked in India, where I was born and raised. I did research, which I never called ‘global health’; I just did research, on TB, malaria, leprosy, diarrhoea, whatever I had to do. Now, I've moved to North America and what I'm doing is called global health research. And over the years, I’ve started to feel uncomfortable about what I'm seeing as the world of global health. There are two statements that are included in all definitions of global health: one, that this is far better than the ‘colonial medicine’ past that it replaces, and two, that global health is all about equity.”
Pai challenges both those statements, with data about how ‘global health’ is in fact determined and managed. Almost 90 per cent of the major global health organisations are based in Europe or North America, and 75 per cent of the board members of those organisations are also based in high-income countries. So are almost all (90 per cent) of the corresponding authors for the highly influential Lancet Commissions, which have done a huge amount to set the international health agenda. The funding for global health is principally from high-income countries – so that inevitably influences the agenda. And 80 to 100% of the major conferences and meetings in this area are held in the highest income countries – for which many potential attendees cannot even get visas to enter.
Pai also looks at whose research is being published and/or disseminated. “There’s been a flood of fantastic research by a whole bunch of people.” However, he points out, it is extremely rare that researchers from the countries defined by the WHO as low and middle-income countries (LMICs) are named as lead author. The editorial boards of journals focusing on global health do include people from LMICs, but usually only around a third; and it’s very unusual to see editors-in-chief from LMICs. “Most global health journals are headquartered in London, even today. And if it's not London, it's New York or Seattle, or Baltimore, but it is not Nairobi or New Delhi.”
One of those rare editors is Dr Seye Abimbola, who is a senior lecturer at the University of Sydney and is also the editor-in-chief at BMJ Global Health. “I'm an African,” he says. “I grew up in Nigeria. For me, running a global health journal and the term ‘global health’ means something different than what they would to many other people, especially the kinds of people who'd otherwise occupy the position I'm occupying.”
Abimbola talks about three issues he has particularly considered. “The first is: who holds knowledge and whose knowledge is valued? That takes in the ways in which we discount local knowledge –which is often tacit knowledge – and our need to rethink how we relate with knowledge. The second is: how do we relate to what colonisation means? And the third is: who has the right to speak to these issues and how do we determine that? When I receive a manuscript, I often ask myself for whom this author is writing. Are they writing for people who are particularly affected by this issue or for an imagined foreign audience? How are they imagining that change happens in global health?”
He continues: “I would like, for example, to see a systematic review on primary healthcare that, for example, takes into account the minutes of meetings of community health committees. Or that takes into account what district health managers discuss on a week to week basis because if we are not looking at these places to understand and for knowledge, we are often just labouring in vain.” At the same time, those processes may themselves be the legacy of a colonial history which has been become part of the current structure of society. “The ‘district’ was the basic unit of colonial extraction: an inequitable system put on top of the previous one. I’m really interested, for example, in advancing our conversations around decolonisation, to really study these ways in which colonisation disrupted local governance mechanisms and how those affect inequities we see in health within countries today.”
Reframing global health
“We want global health to recognise that all human cultures are equally able to help themselves as long as the playing field is equal; that equal does not mean same or even recognisably analogous; and that equal yet different playing fields have become more rare in a ‘one size fits all’ globalisation model,” says Deborah Jenson, Professor of Romance Studies and Global Health, Duke University.
Abimbola makes some further points. “If you understand how colonisation works and how dispossession and disadvantage works, it becomes clear that many academics from LMIC countries are themselves privileged. Often the ways in which we take space, and that we organise space in our discussions around decolonisation and around global health, privileges the privileged. The privileged can be from anywhere. And it's important to recognise that in the ways in which we try to say someone should speak or not speak. I’m also interested in ways in which we create platforms, within LMICs in which we can have these conversations that are no less difficult about decolonisation. There are processes going on within our countries that are very akin to colonisation and we have to find a way to address those processes in the same depth, with the same stridency as we address the Western colonisation and the foreign gaze to which we often speak in our conversations about decolonisation.”
The World Health Organization
“CCH wants to bring the same kind of rigour to understanding cultural contexts as we naturally bring to understanding science and medicine in public health contexts,” says Fietje “There’s no problem with drawing up guidelines or action plans, but when it comes to localising those action plans – translating them on the ground – we often have to rely on individual programme managers, or WHO representatives or ministers of health, who may only be aware of cultural contexts through the narrow lens of their own unconscious biases and haven’t been trained, necessarily, to understand those.”
Professor Sanjoy Bhattacharya, director of the Centre for Global Health Histories at the University of York and of the WHO Collaborating Centre for Global Health Histories, is one of the researchers leading investigations into WHO’s own history. “Far too many scholars, including people who make extremely strong and valid points criticising global health as it's configured today, equate the WHO with its Geneva headquarters. What is often forgotten, by what I call a colonised histography, is that nationalist governments in countries like India and Egypt were active contributors to getting the WHO up and running. Newly emerged countries which had unchained themselves from colonialism were arguing that the new WHO needed to be different from the old League of Nations health section and that it needed regional offices. So from the beginning in 1948, the WHO regional office for South-East Asia was created with its capital in New Delhi – and it was answerable to a regional committee.”
Member states were thus able to direct health policy to a far greater extent than is generally realised, Bhattacharya explains. That included much of the drive towards eradicating smallpox. “It's very important, I think, to decentre our research away from the headquarters to what was happening on the ground, for its rich history of political autonomy, and exchange that is often forgotten in existing scholarship. A lot of this information exists in a diversity of archives, libraries and collections of private papers.”
Uncovering history
Sometimes, Jenson has found, the real story is that disease was imported into an area, rather than lurking endemic in a poor country. When cholera broke out in Haiti in 2010, the widespread assumption was that it must have been there already; it took the work of an investigative journalist to establish that it had in fact come in with UN peacekeeping soldiers who came from a region of the world where the disease was endemic. Jenson looked at the wide range of documents, ranging from memoirs to colonial medical reports from the 18th century on, and found no mention of cholera “Subsequent exhaustive research of 19th-century journalism on cholera in the Caribbean, mostly in the form of ship captains' accounts of encounters with infected ports or attempts to avoid the same, allowed me and my colleague Victoria Szabo to map cholera outbreaks in several successive waves around most of the Caribbean – but never Haiti.”
Moreover, Jenson explains, this absence of cholera was directly linked to Haiti’s independence and its abolition of slavery. “In the cholera epidemics of 1832 and beyond, there were no colonial troops to bring cholera and spread it like wildfire in their close quarters and there were no slave barracks to make that fire into a conflagration. This is a good reminder that legacies of colonialism can create material, infrastructural risks.”
“If we have decided that a small number of people matter and a small number of voices matter, and only what is said in English matters, then we're automatically focusing our attention to a very limited archive, when actually a much wider archive exists,” Bhattacharya adds. “We have to go into the raw material. We also have to look at translations and put them against their originals, to find the silences created through translation and then at how those translations are then quoted selectively at headquarters level. In this way, we can recover voices, experience, and contributions of many more people in global health programmes than we usually study.”
Participants in history
A number of those people are very clear about how they want their contribution to shaping global health recognised. Dr John Manton, a historian of health planning and development at the School of Hygiene & Tropical Medicine, has been talking to nurses and former nurses (mostly men) involved in research on sleeping sickness and Buruli ulcer, in the hospital complex in Ayos, Cameroon. Some of these nurses are themselves former patients, or the children of patients who grew up on the hospital site.
“Among the nurses there is a very strong investment in the place and in the status that comes in working in public health,” Manton says. “People wanted to tell the stories of how medical work had helped them establish themselves as personages, as important people locally and politically, inheritors of the status of colonial nurses. In showing us their place of work, they were demonstrating their right to move through the hospital and show the underlying stories of commemoration, their own association with the health workers and the political stakes that emerged. It also raised questions for us of their presence in the hospital but their erasure from the texts that were written on the research that had been done. They were written out of the research reports.” Manton and his colleagues in fact produced a research report with these nurses’ names at the front as the result of this visit.
The majority, though, are still to be known. “Tapping into tacit knowledge is essentially drawing on the wisdom that individuals have accumulated over the years,” says Dr Meleckidzedeck Khayesi of the WHO. “If you look at the book of Ecclesiastes is in the Bible, it tells the story of the mighty king who came against a city. He surrounded it and was about to destroy it. But there was a poor wise man in that city, and he saved the city. Unfortunately, the story ends on a sad note: nobody remembered that poor man.” He adds: “The public health sector needs to invest in harvesting and utilising tacit knowledge for national health policy planning. Have we truly harvested and made available for use the rich tacit knowledge that is with practitioners, decision-makers, users and communities? I have looked extensively for an example of a country or an organisation that has developed an explicit process, policy, method and a hub for tacit knowledge. I have not yet found one and I am continuing with the search”.
Refocusing history and health
“We want to put out the message that qualitative research is a fundamental component to enhancing the evidence base for policy decision-making [and] that understanding qualitative narratives, lived experiences, is an important component for convincing people of the effectiveness of health policy,” says Fietje.
“Because we attribute power to people sitting in London, Geneva, Washington, New York, we often look for major actors there, and then when we look at low and middle-income countries or emerging economies or poor developing economies, we only look for those voices of people whom we consider to be the main act,” Bhattacharya concludes. “We have to get away from narratives of top-down imposition that assume that only a small number of people matter. We need to look for evidence of decolonised research and reporting. And that evidence does exist: so why not use it?”.
Radhika Holmström is a Wellcome Trust-funded writer and communications specialist working with the WHO Global Health Histories project at the University of York.
