Decolonizing Global Health
Unpacking language, narrative and knowledge
This essay was written in October-November 2021 as an assignment for the Facultad Latinoamericana de Ciencias Sociales (FLACSO) Dominican Republic’s III Curso de Investigación en Medicina Social y Salud Internacional. The article was originally written in Spanish and translated to English with DeepL. Therefore, some of the quotes might not reflect the original text word-for-word.
The language and narrative currently used in global health do not allow for the development of a nuanced perspective on issues within the discipline. These not only perpetuate the unbalanced power dynamics that have prevailed since the days of colonization, but also hinder the dissemination of new international findings to global health researchers and practitioners in non-English speaking countries. Similarly, researchers from the South are constantly challenged and demanded further proof of legitimacy to publish in English-speaking academic journals. Likewise, the knowledge of the Global South remains overshadowed by the voices and desires of the North.
Introduction
The field of global health remains highly penetrated by systems that prevent a true decolonization of its language and narrative. This causes stagnation and impediment to achieving better health outcomes for the peoples of the South. With a critical look at the historical legacy, structures, phrases and words, the aim is to understand how global health has come to what it is now. It will look at colonial language through to that used by international organizations and governments. There will be a section on the use of the English language, another of the difficulties faced by authors from the South in publishing their findings and other problematic strategies and expressions that persist today. On the other hand, this article seeks to expose the language, knowledge and narrative that have been used throughout history in global health, in order to answer the current question: How to decolonize them?
Methods
For this article, an analysis of the rhetoric used in global health from the Global North, which is where the decision makers are usually located, was carried out. To do so, we analyzed, within the existing literature, the decolonization of the language of global health, starting from authors from the Global South in journals indexed worldwide. The search was conducted on the basis of key words such as “global health”, “decolonization”, “narrative”, “language” and “rhetoric”.
Contrary to how global health has unfolded in the twenty-first century, the global South must not be “saved”-its self-determination must be fully respected and cooperation from other actors must respond only to the needs emanating from Southern voices, not the other way around. Appeals to the “white savior complex” may have served to get more funding and feed Northern egos, but they simply get bogged down in the desires of Northern donors and rarely get to the root of the problem. Paola Paredes, a researcher at the University of Granada, explains it this way:
The emotional charge of development narratives, say Cornwall and Brock, is highly identifiable by large international audiences and makes them myths or utopias loaded with “deep ideological constructs” (2005:16). The authors emphasize the lack of neutrality of the terms repeatedly used by international development policies and add that this type of language contributes to reinforce the role of moral authority, of “guardians of what is right and champions of progress”, that supranational organizations have awarded themselves (Paredes, 2016, p. 25).
By this, the author means that the narrative of development is elaborated from the desires of the North to satisfy its agendas for the rest of the world, without taking into account the needs and realities of the South. Everything done and written in the South must coincide with the existing production of the North, since in their imaginary, they are the ones who hold the beacon of progress.
The Use of English as a Lingua Franca in Global Health and Development
It is no secret that the vast majority of academic output in global health is still published only in English. The spread of English has resulted in English-speaking countries dominating the narrative and language of the development sector through the language and narrative they use. This hegemony can result in the loss of identities, cultures, and languages, given the “devaluation of local knowledge and culture” (Safari & Razmjoo, 2016, p. 136). Therefore, it is imperative to recognize the barriers to accessing this literature on the part of international readers. Notably, foreign international health researchers and collaborators, when traveling to another country or region, are rarely required to learn the local language (Hommes, et al., 2021). This fact deepens the unbalanced power dynamics that already exist in this field and that reinforce the status quo of global health and do not enable its decolonization (Hommes, et al., 2021).
The hegemony of the English language in this discipline arises as part of the process of globalization and consequently, “has given undesirable attributes, such as poverty and conflict, to minority languages,” which are seen as impediments to accessing resources and thus increase the desire to learn this language (Gaffey, 2005, p. 14). Gaffey (2005) maintains that “the use of English in maintaining and extending Western power depends on an imperialist discourse through which a hegemonic position of English is created” (p. 7). This means that the widespread use of this language can be seen as a tactic of Western imperialism that discourages the use of local languages and results in their marginalization.
Language, Narrative and Knowledge in Global Health
The suppression of local knowledge and languages to give preference to Western languages, especially English, represents a “form of epistemic violence and racism that is found in development narratives by postcolonial, decolonial, and anticolonial scholars and thinkers as the ‘colonization of knowledge’” (Carrasco-Miró, 2018, p. 154). In that regard, all knowledge developed in the area of health has arisen in part from the silencing of voices from the South and in part from the extraction of ancestral knowledge for the neoliberal economic benefit of the North. As expressed by Quijano (2010):
Let us not forget, likewise, that along with purity of blood, the colony also imposed a purity of knowledge: science was white science. The accumulated knowledge of the native cultures was not and has never been recognized as science, but in general as ignorance, sometimes as empereia, and at most as “ancestral knowledge”; a knowledge only applicable or valid in the indigenous world, but not in the white world, although a large percentage of the drugs marketed by the white transnationals of health owe their great profits to that ancestral knowledge (p. 33).
In this regard, it is understood that the North has not only succeeded in overshadowing the ancestral knowledge of the South, but has also rebranded it, profited from it, and turned it into appealing and easily digestible concepts for Western audiences (Mawere & Awuah-Nyamekye,. 6).
This situation still exists within spaces and strategies created to counter the hegemony of the North, such as South-South and Triangular Cooperation (SSTC or CSSyT, in Spanish), whose “interventions flagged by solidarity — the exchange of knowledge, mutual benefit and sustainable development —have links to colonial narratives” (Carrasco-Miró, 2018, p. 154). The colonizers of Abya Yala maintain an influence in the region that permeates all aspects of development, such as triangular cooperation, which through organizations such as the Ibero-American General Secretariat (SEGIB), allow for an “accompaniment” of the former colonizer in the development of its former colonies (Quijano, 2010, p. 36). The colonialist discourse of white supremacy still lives on in phrases such as “discovery” vs. invasion; “primitive peoples” vs. Amerindian societies […] and in the lack of courses on tropical diseases in medical schools (Quijano, 2010, p. 34).
Moreover, in the rhetoric of development, the Global South is still contemplated as a monolith, a fixed category that does not take into account historical, cultural, linguistic and institutional differences (Carrasco-Miró, 2018). Likewise, the SSTC generalizes and simplifies the relationships between very different states of the South by presenting natural relationships between them (Carrasco-Miró, 2018). Frequently, these relationships carry implicit Western assumptions and stereotypes, falling into the trap of neocolonialism, even if unconsciously.
The problem of the colonization of language always comes back to the same problem: it is not possible to work from the same neocolonial and neoliberal structures that prevail. Some of the expressions used in this regard from the institutions of the Global North are “leveling the tilt towards the North”, “dismantling the master’s house” and “passing the microphone” to amplify the voices of middle and low income countries (Naidu, 2021, p. e1332). Under these narratives, unequal power relations are maintained, as the power of one and the subjugation of the other is implied.
Global Health Problematic Terms and Strategies
The expression of terms within the language of global health is one of the great challenges facing this discipline. One of these problematic terms within the field of global health is the expression “tropical medicine”, which preserves imperialist notions and, unfortunately, its use continues to this day, when prestigious institutions carry it in their name (Hommes, et al., 2021). Similarly, other widely used terms that preserve the colonial air are dichotomies, such as “high income countries” vs. “middle and low income countries” and “resource-rich countries” vs. “resource-poor countries”, which reduce countries and their cultures and make them one-dimensional, by not taking into account the historical, social and cultural processes they have gone through (Hommes, et al., 2021, p. e897).
Another problem that prevails when talking about global health is the nomenclature of diseases, which follow colonial patterns of naming them according to their colonial discoverers, according to the country or region in which they were discovered (colonial terms such as cutaneous leishmaniasis of the Old World continue to be used) (Hommes, et al., 2021). Thus, it is necessary to dismantle not only the colonial language in global health, but also the inequality and power structures it sustains.
On the other hand, a host of public health campaigns have focused on “framing health as the responsibility of individuals and communities […] from instructing parents to vaccinate their children to warning against risks from illegal substances” to shape individual behavior (Hsu & Lincoln, 2009, p. 20). Historically, Northern governments have used the rhetoric of “hygiene” to monitor the behavior and movements of immigrants and colonial subjects, which served to stereotype hygiene and sanitation (or lack thereof) by some groups (Hsu & Lincoln, 2009, p. 20).
Ethnography and Coloniality
Ethnography is a type of qualitative and anthropological research that “requires an epistemological rethinking that forces us to overcome some of the bases of positivist paradigms, such as the subject-object separation” (Romaní, 2013, p. 10). This research tool is not new; however, it should be noted that in its beginnings, the first anthropologies and ethnographies conducted in the field of health were carried out under an “exoticist and primitivist regime, and expressed the conceptual equation ‘science, magic and religion” (Epele, 2017, p. 363). It is not surprising that these early instances of ethnography in the Americas were conducted by American anthropologists, as the repertoire includes “speaking for others; translating the realities of others into terms of our own; […] devaluing and silencing local and subaltern knowledges and practices of the global south through the coloniality of Western models; revising the epistemic-political bases of authority over the ethnographic telling of the suffering of others…” (Epele, 2017, p. 363). Since a large part of ethnographies have been written from the lens and pen of Northern researchers, so too are the grievances, injustices, and needs of the South interpreted from the North.
World War II brought with it the creation of the United Nations, the World Health Organization, the Pan American Health Organization, among others, who would dictate the new paradigm of health policy development (Epele, 2017). The researcher María Epele, from the University of Lanuz, Argentina, exposes that after the creation of these organizations, there also emerged “a wide repertoire of discourses, institutions and interventions aimed at modifying the morbimortality of those regions and countries included in the — recently categorized — ‘third world’, which persists in different programs and plans to this day” (p. 363). In this regard, Epele (2017) maintains that from these international organizations emerged “frictions between Western and native biomedical models” (p. 363). Thus, biomedical knowledge was consolidated and legitimized as universally valid, while local beliefs about disease were considered “wrong” and needed to be corrected (p. 363).
Power and Brennan (2021) describe the example of the British South Africa Company (BSAC), which was granted by the British Crown the administration of the colony of Rhodesia (now Zimbabwe), and its accountability for the deaths of the locals. In that case, the BSAC used accounting to dehumanize the inhabitants of that colony. This too is part of the violence and injustice carried out in global health-not only the description of what happened, but also its quantification. Plantation accounts “commodified, objectified, and dehumanized an entire class of people, the slaves” (Power and Brennan, 2021, p. 2). The annual reports were “addressed to a distant audience in London” and the reports reflect that colonial mentality (p. 2). The language of abstraction was used when quantifying the deaths of locals, and silence was used as a tool to hide the suffering of enslaved peoples (p. 2).
Strategies for Decolonizing Language, Narrative and Knowledge in Global Health
To counter the concentration of language and knowledge in the North, epistemic thinking arises, which criticizes the existing academic bias, mostly written and edited by white men based in high-income countries (Naidu, 2021). The author, Dr. Thirusha Naidu, Department of Behavioral Medicine at the University of KwaZulu-Natal, Durban, South Africa, explains that the supremacy of Global North countries in the creation of knowledge in health is due to the gatekeeping maintained by these academics.
There are three strategies, according to Dr. Naidu, by which middle- and low-income countries academically oppose the Global North narrative. These are, first, to expose these ideas developed by thinkers in high-income countries back to these countries, but from the Global South, which the author calls “northern ventriloquism”. The second strategy she proposes is to “articulate local ideas in local spaces” (Naidu, 2021, p. e1332). The third, “subverting the domination of high-income countries through academic insurgency,” or epistemic disobedience (Naidu, 2021, p. e1332).
In her essay, Dr. Naidu makes a critique of reputable academic journals such as The Lancet, which have made great commitments to gender equity and author diversity, but not from intersectionality (Naidu, 2021). It argues that anti-racist and feminist perspectives from high-income countries favor white women and black men, respectively, and promotes ideas from the Global North, for the Global North.
It is true that Global North researchers have assumed an attitude of “objectified silencing” of their Global South counterparts, treating them as resources from which Northern countries have been able to collect and validate information through their Western structures (Naidu, 2021). Therefore, it becomes necessary to take into account the ethical implications of such actions, apart from their implied value of universality, which overshadows the voices of the South (Naidu, 2021). Simply acting as a health researcher from a high-income country in a middle- or low-income country becomes problematic by intentionally or unintentionally silencing local voices.
By publishing, researchers from the South are required — although implicitly — to support the existing literature in the North. Failure to do so makes it extremely difficult for these researchers to publish their work in journals in high-income countries, as Dr. Naidu recounts in her testimony. She states that the objectivity revered in Northern academic output in global health does not reflect the reality of researchers and health workers in the South, which tends to be a “social, survival-related, and personal” experience (Naidu, 2021, p. e1333).
Given the high barriers that Southern researchers face in having their work taken into account in the North, many of them collaborate with Northern researchers to “Westernize” their language and achieve greater legitimacy vis-à-vis institutions in high-income countries (Naidu, 2021). Likewise, Southern thinkers are faced with the dilemma of publishing for a local audience in their native language, or publishing for an international audience in the English language (or any other language traditionally spoken in the North) and risk falling into the trap of Northern ventriloquism.
Recommendations
To achieve a true decolonization of global health, it is essential to take into account the recommendations emanating from the South. These include promoting abstracts in the mother tongues of researchers from middle- and high-income countries and indigenous languages in the countries where this research takes place; establishing multiple platforms to facilitate access for Southern researchers to publish and present their work; allowing creative freedom for Southern countries to write from their own experience, no matter how “subjective”; and finally, supporting Southern authors and validating their lived experiences while systematically analyzing the implicit biases of publishers (Naidu, 2021).
More research should be done on the feasibility and process of removing colonial disease names from health systems. Similarly, the inclusion and validation of local, indigenous and alternative health knowledge and practices should be pursued to achieve better life expectancy and quality of life for the peoples of the Global South.
Khan, et al. (2021) recommend building on the momentum generated by 2020 in decolonizing health and demanding accountability from the organizations that concentrate all the power (p. 3). They argue that there must be a shift to community organizations on the ground, who for the most part, are the ones who really create impact and evoke the change this sector needs. However, they argue, “rhetoric is much easier than reform when power and privilege are at stake” (Khan, et al., 2021, p. 3).
Conclusions
Global health is a discipline that for centuries has been directed and governed by the Global North. However, this bias does not allow the voices of the South to be truly heard, which requires a decolonization of their language, narrative and knowledge to achieve truly inclusive and effective global health. The use of English as the primary language in most international health research and programs hinders communication, silences local voices, and undervalues Southern research. It is important to recognize that many of the institutions conducting international health today are led by a few folks in the North. Similarly, the use of colonial terms for naming diseases, for example, and the writing of ethnographies should be closely scrutinized. Finally, the demands of the South must be taken into account, as the South has been subjugated, first by colonial, then explanatory capitalist, and now neocolonial systems. If health is to be truly decolonized, we need to begin with its rhetoric.
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