Colonialism in Global Health And How to Avoid It
Interest in global health is at an all-time high among medical trainees and for good reason. As globalization makes our world smaller, it becomes more and more unconscionable to tolerate disparities in healthcare based on where someone was born. Concurrently, people have also begun to discuss the colonial roots of global health. Whether it takes the shape of medical tourism, white man’s burden, or proselytizing Western ideals, global health practiced irresponsibly can do more harm than good.
I say this as a graduate of HEAL (Health Equity Action Leadership), an interdisciplinary global health fellowship housed at the University of California San Francisco that trains doctors, nurses, and other health professionals to ethically provide care in low resource settings, domestic and abroad. Thankfully, HEAL is acutely aware of the dangers of perpetuating colonialism and has actively taken steps to avoid it. They placed me, an Indian-born American citizen, in India for better cultural adaptation. We had three weeks of didactics on topics such as power and privilege, structural violence, and one titled “decolonizing global health” prior to deployment to our respective sites. In addition to the good-intentioned Americans interested in health equity, they also recruited trainees from the international sites so that we could learn about these concepts side by side. Duration at these partner sites was six months to a year so that we could begin to understand the communities that we came to help.
“My foreignness was an asset in India, while in the United States, it would have been a detriment.”
Despite all of these safeguards to avoid colonialism, the power differential when I went to India was palpable. I am Bengali, but the hospital I worked at was in the Hindi-speaking state of Chhattisgarh. I had the audacity to practice medicine in a language I did not know, a situation that would be unfathomable if an Indian doctor applied to practice in the US without basic knowledge of English. Even worse, some patients valued me more because I could not speak Hindi. They went out of their way to come to this hospital because they felt that they were getting special care from outside the country. My foreignness was an asset in India, while in the United States, it would have been a detriment.
When seeing patients, I often found myself applying US standards to Indian contexts. The first time my resident discharged a patient with a hemoglobin of 5 (less than half the blood a healthy person would have), I was confused and taken aback. However, the reality is that blood is at a severe shortage in India, especially in rural areas, due to a difference in cultural norms. Donating blood is thought to cause weakness or impotence. Grown men would refuse to donate blood for their mothers, wives, or children. In this environment, it was perfectly reasonable to target a hemoglobin of 5 as a matter of resource scarcity and allocation.
As another example, I was initially uncomfortable when we gave patients chemotherapy for a suspected diagnosis of lupus-induced kidney failure rather than a biopsy-proven one. In the US, we would typically confirm our diagnosis before administering a toxic treatment with significant side effects. However, a kidney biopsy was simply not done by anyone within a three-hour radius of the hospital. Thus, our options were either to give chemotherapy based on the most likely diagnosis or do nothing and watch the patient die of kidney failure in a setting where there is no dialysis. Given this context, the choice was obvious. Give the chemotherapy and swallow the risks. It took me time to overcome my colonial mindset, which was only possible because I was placed in India for six months at a time. Had I gone there as a resident on a one-month rotation, I would have left with the impression that this hospital was practicing substandard care rather than care sensitive to the resources available.
“Had I gone there as a resident on a one-month rotation, I would have left with the impression that this hospital was practicing substandard care rather than care sensitive to the resources available.”
Most of the help needed in global health is structural rather than clinical. However, changing the structures that lead to inequity requires a long-term commitment. Creating a culturally competent campaign for blood donation or setting up referral systems to get people the biopsies they need is arduous work that requires developing and maintaining relationships –work that is best left to people with an in-depth understanding of local systems. Understanding the way a community functions and how it fits into the larger structures governing it takes longer than a two-week mission trip, a one-month rotation, or even a six-month placement. Thus, my global health philosophy has shifted toward either making that long-term commitment or supporting the local personnel and infrastructure that will be around long after the volunteer leaves.
That is not to say there is no role for outsiders in global health. Being aware of our potential for colonialism is the first step toward decolonizing global health. I believe the second crucial step is solidarity. We must ask our international partners how we can be of help rather than impose our ideas of how we can be of help. We must trust our brethren to understand their needs better than we do. For example, I was asked to provide medical education in India, and at other sites, assistance with quality improvement is requested. Fulfilling these two needs, which are often deferred due to the high clinical load at underserved sites, can have an impact that lasts far beyond the time served.
“Being aware of our potential for colonialism is the first step toward decolonizing global health. I believe the second crucial step is solidarity.”
Muso Health, a global health organization based in Mali and San Francisco focused on redesigning health systems, has formalized the concept of solidarity. Not only was it cofounded by the two countries with equal footing from its inception, but they hire locally as much as possible. Furthermore, they actively solicit patient perspectives to guide policy changes. By incorporating many different local voices into their work, Muso avoids colonialism and instead promotes its opposite: returning power to the people they came to serve.
The third step is focusing on doing less harm rather than trying to do more good. We must analyze the part we play in causing the global structural inequities we go abroad to fix. For example, we can advocate for pharmaceutical patent reform to make drugs available in the global north available worldwide. We can be more cognizant of creating diverse cohorts for our clinical trials so that the majority of the scientific literature is no longer specific to a Western Caucasian population, or better yet provide funding for researchers in less-resourced areas to answer the questions that are relevant to their communities. We can reduce our carbon footprint and wage less war, both of which disproportionately affect the poor and widen the wealth gap.
Unexpectedly, doing a global health fellowship has, for the reasons above, convinced me to stay in the US. My medical school and residency training were at a public county hospital serving marginalized populations such as refugees, undocumented immigrants, the uninsured, and the incarcerated. Although I cannot claim to be a part of any of these communities, I do believe I have a better chance of understanding and intervening on the structural violence they experience than I would in India, in part because I also live in (and benefit from) the same structures as these patients. Having a fellow eschew future international work for a stronger commitment to domestic underserved populations may seem antithetical to a global health fellowship, but quite the contrary, this is exactly what decolonizing global health looks like.
Abhi Kole is an alumnus of the HEAL Initiative Fellowship in Global Health Equity. He currently practices hospital medicine at Grady Memorial Hospital in Atlanta, GA.
Global Health Corps (GHC) is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. To learn more, visit our website and connect with us on Twitter/Instagram/Facebook.
