More work needed to rid global health of colonisation

There is a need for continued exploration and publication within academic global health to build an anti-colonial curriculum in the field, a recent study argues.

“Anti-colonial education in global health is essential for addressing structural inequities locally and globally,” authors Sylvie Perkins, Holly Nishimura, Praise Olatunde and Anna Kalbarczyk write in their study ‘Educational approaches to teach students to address colonialism in global health: A scoping review’ that was published in the journal BMJ Global Health earlier in 2023.

Though there are publications in academic global health discussing proposed guidelines and competencies related to anti-colonial public health and describing or evaluating related educational approaches, “there is a paucity of literature exploring meaningful pedagogical and systemic change”, they say.

Perkins is from the Centre for Indigenous Health at Johns Hopkins University’s Bloomberg School of Public Health in Baltimore, Maryland; Nishimura works in the department of medicine at the University of California’s San Francisco School of Medicine; and Olatunde and Kalbarczyk are at International Health at Johns Hopkins.

A Decolonising Global Health Working Group report published by the University of Washington says “the primary aims of decolonising global health practices are to achieve equitable collaborations, centre projects around local priorities, diversify leadership, and promote respectful, collaborative interactions and language or tone in all communications”.

Set of approaches

Perkins and her co-authors say the term “decolonise” used throughout the study gives its consistency with the current dialogue around this topic. They acknowledge the significant gaps in the use of the term, “including its potential use as a metaphor rather than instigator of change, its disregard for associated violence and a lack of attention on the underlying white supremacy ideology”.

The researchers conceptualise anti-colonial education as a “set of approaches that can contribute to the decolonising global health movement”. They define anti-colonialism in global health education as “training practices focused on dismantling colonial legacies and neo-colonialist control and influence in global health and across majority world health systems”.

In their view, neo-colonialist control resulted in and still maintains hierarchies in career opportunities, research partnerships, teaching practices, care practices and funding opportunities in global health. These hierarchies privilege Western “actors and systems (of knowledge, health, and social organisation)” above those in the bigger part of the world.

In the study, they also looked at anti-colonial education in global health and concluded that this offers “approaches that take an active stance to address wide-ranging structural issues that include (but are not limited to): colonialism or neo-colonialism, cultural hegemony, global health ethics and bioethics (focused on systems and structures), global health engagement, structural violence, structural or systemic racism, structural inequalities, structural competency, systems of power and privilege in global health, white supremacy, white saviourism”.

Eurocentric stance reinforced

The study, which is a scoping review of the published literature, was conducted to provide a synthesis of guidelines for and evaluations of educational approaches focused on anti-colonial education in global health. Five databases were searched using terms generated to capture three concepts: ‘global health’, ‘education’, and ‘colonialism’.

They found 1,153 unique references and 28 articles were included in the final analysis. The articles centred on North American students, their training, their evaluations of educational experiences, their individual awareness, and their experiential learning. Few references discussed pedagogical approaches or education theory in guidelines and descriptions of educational approaches. In addition, there was limited emphasis on alternative ways of knowing, prioritisation of partners’ experiences and effecting systemic change.

The study also found that several authors from lower- and middle-income countries (LMICs) and other marginalised communities have written about the process of decolonisation within health research; from conceptualisation to grant agreements, administration and accountability to the importance of non-tokenistic representation of collaborators from LMICs in publications, editorial leadership, grants and project leadership.

In addition, they noted the role of global health education programmes and institutions in perpetuating inequities and colonial ideologies has been similarly explored. Global education has been widely criticised for reinforcing Eurocentric standpoints and ways of seeing the world.

“This is, in part, due to the colonial origins of the field of global health. Early international health organisations stemmed from colonial health authorities. Their programmes were situated within colonial settings and their employees frequently transitioned between international health organisations and colonial health authorities, blurring distinctions between the two,” they say.

Medical education a colonial institution

What this meant was that global health was centred on the health and economic well-being of the colonists and employed colonial rule to force health interventions on the colonised, regardless of the negative impacts. This fed into the creation of international health education programmes established by these same organisations and remains inherent in the more recently defined field of global health education.

According to the study, present medical education in colonised countries, past and present, is a colonial institution that gives power to European systems of knowledge and erases other ways of knowing.

Most global health programmes are based in high-income countries (HICs) and serve HIC students. Tuition, in conjunction with living and travel costs, make these programmes inaccessible to students from LMICs. Short-term experiences in global health, whereby students from HICs travel to LMICs to conduct research or practise, are a staple in many global health programmes.

“Efforts to incorporate anti-colonial principles into global health education can operate at multiple levels to detect and disrupt the remnants of colonialism that impact health. First, curricula and pedagogy play a critical role in the validation and-or marginalisation of people and systems of thinking and, therefore, must be reimagined through an anti-colonial paradigm to decolonise global health,” the authors argue.

In addition, they say, education provides a mechanism for anti-colonialist praxis through critical self-reflection, co-created curricula, bidirectional learning and equitable partnerships. They note that anti-colonial education has the potential to mobilise global health practitioners and researchers who acknowledge the role of colonialism in perpetuating systems of inequity and actively pursue ways to recreate them.

No consensus in other disciplines

“Other academic disciplines such as education, anthropology, sociology, and women’s studies have been grappling with the operationalisation of anti-colonial education, and yet there is still no consensus.”

The study found that, in these fields, anti-colonial education has included the visible aspects of what is taught (curricula) and how it is taught (pedagogy) as well as the hidden curriculum and epistemologies. “When presenting incorporation of anti-colonial principles into global health education as critical to the decolonising global health movement, it is important to note that truly decolonising global health will only be actualised through dismantling colonial institutions and decolonising the world’s political economy.”

Educational environment can be described as the institution or system in which education takes place, such as a university or community organisation and its partners and collaborators.

The authors recommend the development of institutional task forces that would be responsible for ensuring that students and faculty prioritise health equity in all global health activities. Specifically, individuals can consider alternatives to achieve the same personal outcomes or reorient their expectations to align with the expressed desires of the community. Programmes can shift focus to sustainable, community-defined outcomes and implement communications campaigns about ‘responsible’ engagement, and society can implement policies aimed at more rigorous admissions protocols and comprehensive monitoring and evaluation.

They write that decolonising global health initiatives has largely focused on research and partnerships and that their study fills a major gap by synthesising the literature and identifying important gaps that must be addressed to further decolonise global health education.