If you listened to the NPR podcast about the case in Jinja, Uganda, you are probably shocked. How could a young American girl, full of good intentions and the desire to help poor children in Africa, attempt to treat malnourished children with no medical qualification for that? This fact was a sad tragedy, an extreme case with many deaths that does not represent the reality of most actions in global health. However, this case showcases a mentality that is behind most global health initiatives to help impoverished people in the global south: the paternalist colonial mentality behind actions, that address immediate needs helping those lucky enough to benefit from some healthcare offered, but actions that do almost nothing to emancipate people for their socio-economic and intellectual independency.
The first part of this text ended questioning whether global health initiatives contribute to promote colonialism in a new, veiled form. After understating a little bit what colonialism means today, I presented four questions. Attempting to answer to them might help us to understand the relationship between global health and colonialism. These questions are about four key aspects that guide global health initiatives: methods, leading actors, funding, and mentality. How are those aspects present in global health? This text now is a small preliminary attempt to address these four issues. It is preliminary because I am still working on them and here, I offer a taste of something I hope to develop in a more comprehensive and technical work.
The case occurred in Jinja is iconic to understand the methods, the leading actors, the funding, and the mentality that guide most global health initiatives. Renee Bach, the American woman from Virginia at the center of this tragedy, went to Uganda feeling that she was responding to a vocational call to help the poor. Full of unquestionable good intentions in her twenties, Ms. Bach began a work in Jinja to support poor children in the way she thought was right to address what she “knew” they needed. Everything was from her perspective and under her directions. This is the most common method in global health, that is, an approach led by outsiders (the leading actors) who think they know the local reality better than those who live there. Ms. Bach could begin this work because she was supported by donations from people back home in Virginia, mainly people from her Church community who believed in her mission and admired her vocation to go to a poor country to serve the poor. These donors certainly shared the same belief with Ms. Bach and trusted in her conviction that she knew how to help these people. Pictures of her with poor children in Jinja probably were showed in her Virginia community to motivate donors to support her work. This points out to the questions of whom funds global health initiatives in low-income countries. Although individual donations to support charity is a noble act, the funding question becomes an issue when you realize that most funding for this kind of initiative comes from acts of philanthropy of corporations and very rich people in exchange of benefits they receive for doing that. (It does not seem this was a source of funding in the present case, and I will address the problem of certain forms of philanthropy later.) Finally, all described above is guided by a mentality, a worldview shaped in the rich global north that knows what is better for the entire world. This provides the support that people, like Ms. Bach and her supporters, organizations, and even governments from the USA and Europe, have the right to go to another country and tell people there what they should do to improve their lives. This improvement suits the Western culture, intellectuality, and model of development, maintaining a relationship of dependency. The children of Jinja would have healthcare as long as Ms. Bach’s group was offering this service for those kids lucky enough to find her. They could not do by their own. They were too primitive. Hence this led Ms. Bach to think that she knew more how to treat malnourished children than a Ugandan physician or nurse. Although extreme, this example shows how global health initiatives become an instrument of promoting a new form of colonialism, that prevents nations from socioeconomic and intellectual emancipation, resulting of a collaboration among peers.
Most global health initiatives do not end in tragedies, but rather help people in some of their immediate needs. For instance, a clinic supported by US physicians in a poor area helps a poor sick person living in this region. Questions about colonialism and global health are not as explicit as in the Jinja case. The relationship is very subtle, hidden by the good met by individuals in their immediate needs. If I am very poor and hungry today, I will be glad when I find a charitable person to feed me now, but I will be hungry again tomorrow. If nothing changes in the way I can support myself, I always rely on the luck of finding another good person, who has economic autonomy, to help me again, so I don’t die starving in my economic dependency. When we see the big picture of the reality where people in need live and why they are in a condition of economic dependency, limited services to relieve immediate needs do not go beyond a palliative effect for the majority of beneficiaries and have no real social impact towards development. It seems to me that helping people in their immediate needs must be followed by actions for their individual and economic emancipation, a follow up that is lacking in global health. Let’s understand this by looking at: methods, leading actors, funding, and mentality.
Methods: Most global health initiatives have a top-down approach, a common perspective that shapes methods used by organizations, schools, groups, and international governmental partnerships in global health, most of the time Western entities from a rich global north country acting in the poor global south. A top-down approach means a rich nation – through entities mentioned above ranging from a small group as the one in Jinja, to a US university, to giant organizations such as World Bank and the World Health Organization – developing any global health initiative in a poor country from a narrow perspective shaped by the worldview and assumptions of the wealthy nation, dismissing an active collaboration and agency of people from local communities. It might function as another form of colonialism because it is a top-down approach led by rich nations imposing their worldview and values into poor countries and communities.
The discussion about global health governance makes clear this top-down approach and those who advocate for centralization of global health actions, centralizing them in a leadership from the global north and its organizations. When one visits a field where health care is delivered, it is clear to see methods of controlling and guiding from above, in the hands of outsiders, people from wealthy countries sponsoring the mission, or a person who might be a native from the region, but was educated in the Western mentality and feels obligated to follow perspective determined by the sponsor. Therefore, it is not by chance that centralization is the mainstream perspective in global health governance, with actions, projects, and systems being controlled by a central power located in the countries from where organizations are from and even a global centralization in which the WHO or UN would have (de Campos, 2021). In a context highly marked by a top-down western approach, more centralization in the top has been the method that many global health leaders have advocated for addressing issues of governance and healthcare delivery in local realities.
Leading actors are those who are promoting and/or following the top-down approach. This approach and the leading actors have a natural correlation and interdependency. Once the top-down approach is from the global north with a worldview limited to Western epistemology, the leaders of global health are people who, consciously or subconsciously, embrace this view. They are professionals and officials from the global north acting in the field as chief strategists, managers, researchers, professors, clinical directors, medical providers, and others with more specific roles. However, they are not the only ones. They are also those leaders who are not in the field in the poor regions but work from an office in a global north country directing actions in a low and middle-income nation. And we can’t forget those who are from the host country, a native, but operate under this external leadership and/or inside the Western mentality, what mostly leads to dismiss their own local epistemological framework. This is related to the question about mentality, that will be addressed later.
Once, serving in Uganda, I heard something that illustrates this very well:
I am a Buganda person and I don’t think like you. Foreigners and missionaries come here to help us, like you. They do a good work, but they do not trust us. They treat us as if we are incapable of doing anything right. All the good work is attached to foreign missionaries and their international groups of people. They make us to be dependent on them and accept everything they are saying. We are helped when we are sick, in our immediate need, but we never advance to an independent life and to grow in a Buganda way (Archelo).
Funding: Global health initiatives cost a lot of money. Healthcare delivery is not cheap. Who pays for all these initiatives? As I said above, global health includes a large range of actions. Hence, there are many different funding sources that vary from government funding and grants (such as those from the US Agency for International Development) to private donations from rich individuals and corporations (through philanthropy), to even people paying to do something in a low-income country (such as students paying to go to a global health trip promoted by their schools, what has become a commodity for colleges and universities to sell). What all have in common is that these funds come from people and government in rich nations. (A potential question is whether only people from rich nations donate to global health: the answer is no. People from other nations also contribute, however, the money that come from these global south donations and the influence they have are insignificant compared to the dollar amount and the power coming from the global north.)
Who funds global health is also a leading actor, once he/she has the power to determine how the money should be used, where, and by whom. For example, USAID determines how the funds they provide to organizations are used. Very often, this goes along ideological views of whoever is in the power in the US government. For example: the way USAID funds are used in women’s health changes every time that US federal administration switches between Republicans and Democrats. Funding coming from philanthropy operates in similar way. NGOs develop projects that please sponsors. Both NGOs and philanthropists operate according to what they think are important for a poor area. They rarely listen to the poor people from this area and ask what they need. In addition, cost-effectiveness is the realm of using funding. This is clear, for instance, when one realizes that most global health actions target communicable diseases, grounded on the argument that people in poor countries are mostly dying because of these diseases and addressing them is cost-effective. Non-communicable diseases, such as cancer and cardiopathies, are more expensive to address and more prevalent in the global north. This view ignores the reality of low and middle-income countries, where most deaths because cancer and heart diseases occur (Ezzati at al., 2018.). In addition, the lack of hearing local communities and understanding their reality, needs, mindset, and culture leads to conflicts and inefficient practices. In his book about the Ebola outbreak in Western Africa, Paul Farmer shows this conflict when he realized that most decisions to stop infections were made to focus on forbidding certain cultural practices considered by outsiders as the main reason for the spread of Ebola, while neglecting care for those who were sick (Fevers, Feuds, and Diamonds: Ebola and the Ravages of History).
When one thinks about students going on global health trips promoted by their schools, many issues could be raised. I don’t have space to address them here. I only say that these trips must be critically re-thought to challenge the mainstream view about students (not yet qualified workers) traveling to an impoverished region to help the poor. It seems urgent to re-think this view to incorporate a perspective of companionship, which students engage in an experience of learning from people and communities. Thus, students are the ones who are helped by being challenged to see beyond a Western and privileged life. (I also think about the money students and their parents spend in these trips. Almost none of this money is transformed into concrete benefits for host communities. If one takes only the money spent on air-tickets and sends it to a local project, it will have a positive impact that a visit of a group of students, who most of the time even don’t speak the local language, can’t have.)
However, the most important criticism about the funding going toward global health initiatives is related to colonialism. With extremely rare exceptions, these initiatives do not promote economic and intellectual emancipation of global south nations, rather they create more dependency of external support. Even undesirable by most people serving in global health, these actions and their system of funding contribute to sustain the current neoliberal and exploratory capitalist system that generate the poor and the oppressed that global health activists serve. Consider, for instance, the practice of philanthropy: this beautiful generosity has supported many nongovernmental organizations that address global health issues in low and middle-income countries. Although there are some merits of this practice, philanthropy fails to address the structures responsible for injustice and poverty, the main cause for poor health, lack of healthcare assistance, and premature deaths.
“When I give food to the poor, they call me a saint. When I ask why the poor have no food, they call me a communist.” This statement by Brazilian bishop Helder Camara reflects that current system likes philanthropy because it does not question the structures. When those structures are questioned, the powerful people feel threatened. Camera affirmed:
But I have not come to help anyone to delude themselves by thinking that all we need is a little generosity and social work. Of course, there are cases of shocking poverty to which we have no right to remain indifferent. Very often, we have to give immediate assistance. But don’t let us think that the problem is limited to a few minor reforms, and let us not confuse the beautiful and essential idea of order, the goal of all human progress, with impoverished versions of it that are responsible for keeping in place structures that we all recognize cannot be retained. If we want to get to the roots of our social problems, we will have to help the country break the vicious circle of underdevelopment and destitution (Essential Writings, p.40).
Global health should include this questioning, even challenging its own financial supporters, otherwise it will be a failure against colonialism that lacks to recognize the individual faces and dignity of those who are suffering. Although people far from them want to help the poor, these philanthropists do not want to know them, they are still inferior, therefore, they are not sympathetic to their cause for justice and emancipation. Simone Weil says that keeping them as them and never part of us is a way to make people in rich countries to feel good about their own actions (Les Nouvelles donnés du problème colonial dans l’empire français, p. 419-424). Consequently, philanthropy is more an action to make the philanthropist look lovely than to change the world into a place of justice where the poor are empowered to be agents of their own lives and their development shaped by their worldview and control of their natural resources. Once I heard from a colleague that this practice of philanthropy is one of the cruelest faces of modern capitalism because it makes capitalism appear generous. On the one hand, it keeps the poor alive, poor, quiet, and thankful for receiving crumbs that fall from the table of the rich. On the other hand, it solidifies the structures and status quo that continues exploiting the poor and preventing them from making their own revolution. As Camera affirmed, we cannot only feed the poor and we must ask why they are poor.
Mentality: in a simple sentence all presented above is sustained by a colonizing mentality that is still guiding the modus operandi of people in the global north, but also present in people’s mind in global south through a colonized mentality. In the book mentioned earlier, Paul Farmer recognizes the ramification of colonialism and the colonial rule of Europeans in Western Africans, and the way public health experts handled the Ebola epidemic. According to him, they were still using colonial language to blame native’s customs for the appearance of Ebola in humans (a zoonosis disease); they used punitive practices of public health and follow a “control-over-care paradigm” that neglected care for those who were infected (Fevers, Feuds, and Diamonds, p.xxvii). In addition, Farmer suggests that, although African physicians affirm that the colonial rule was in a remote past, it influences their lives “in the contingent ways that historical precedent always does” (p. 103). This history of oppression and domination is also a history of disease control to prevent infections in the colonizing nations, not to help people in the colony (p. xxvii). In the Ebola epidemic, we saw it once again. European Countries and the USA only looked at the suffering of African nations when this would serve to their self-interest in keeping Ebola far from the global north. The people who get infected, sick, and die in the global south are not the same, in level of humanity and dignity, as people in the global north. With the COVID-19 pandemic, the situation is very similar when we see issues with vaccine nationalism, economic protections to favor rich nations in the health market (Eyawo; Viens, 2020), and the disparity that only one percent of people in low-income nations are fully vaccinated, compared to over 50% in the wealthy ones. The latter are now talking about booster shots, while poor people have no idea when they will have an opportunity to receive an initial dose.
Unfortunately, our world is still dominated by a colonial mentality in the relationship between north and south. Global health is not immune from it and might be another instrument to perpetuate it. Colonial mentality prevents nations and peoples from their emancipation, so they could be who they are grounded on their own epistemology. Sousa Santos says that epistemologies of south challenge the Cartesian, colonialist paradigm of dominating the nature and people. Because the colonial history and its action to diminish non-European people, the colonial mentality is also present in the minds of people from the global south. In 1952, Frantz Fanon, a Black man from Martinique who joined to the Algerians in their fight for independency from France, affirmed: “A white man in the colonies has never felt inferior in any respect whatsoever … Inferiorization is the native correlative to the Europeans’ feeling of superiority” (Black Skin, White Masks, p.73). This represents very well the mentality that guided Renee Bach’s work in Jinja and those Ugandans who trusted her. The same guides many global health initiatives, placing these initiatives very far away from any contribution to a project of emancipation of knowledge with economic and intellectual independency.
According to Fanon, the colonizing man “produces the feeling of inferiority in the native” (p. 88). This is so strong that when the native fights for liberty and justice, “it is always for a white liberty and a white justice, in other words, for values secreted by the master’s” (The Wretched of the Earth, p.195). Although Fanon seems pessimistic, I think there is a way to begin to change it and global health can offer a contribution beyond addressing immediate health needs of the poor. Paulo Freire points out that the liberation towards justice and emancipation of knowledge begins with liberation from the colonial mind through a process of conscientization led by the oppressed. Hence, the oppressed can liberate themselves and also the oppressor who never will act for liberation, but need to be liberated. This process of liberation must be part of global health, if we want global health initiatives as part of the solutions and not a tool that helps to perpetuate new forms of colonialism, disguised as health goods delivered for the poor.
*Alexandre A. Martins is 2021-22 Hubert Müder Chair in Health Care Ethics at the Albert Gnaegi Center for Health Care Ethics - SLU; an assistant professor at Marquette University in Wisconsin, USA. Author of several articles and books in social ethics, bioethics, and global health, such as Covid-19, Política e Fé: Bioética em diálogo com a realidade enlouquecida (Gênio Criador, 2020); The Cry of the Poor: liberation ethics and justice in health care (Lexington Books, 2020)