Ankit Raj: The unequal dynamics of global health—are we still colonial at heart?

We still have a way to go to reach equity in global health, says Ankit Raj

Let’s start with me: I am a junior doctor with considerable experience of working in lower resource settings, a decent research background, and interests in health policy and systems strengthening. Yet I will not qualify for many global health opportunities that my peers in higher income countries will be fortunate enough to receive. While the scope and boundaries of global health have stretched beyond imagination, it is, in many ways, still shaped by colonial power dynamics.

I have heard other versions of this same story from my colleagues across the global south: a certified doctor who wasn’t ”qualified enough” to attend a surgical elective in Europe, an expert on malaria who couldn’t get a visa to attend a tropical medicine event in the US, an applicant to a masters in global health who couldn’t scrape together enough money to attend an expensive Western institution, and a medical student who didn’t get his name featured on a paper that analyzed data from an institution in a low and middle income country (LMIC) where he collected most of the data.

In contrast, on Instagram and Twitter, it’s always been easy to come across physicians from high income countries (HICs) posting pictures of their “parachute missions” or “surgical safaris” while vacationing at a jungle safari, or to find medical students conducting research studies in south Asian institutions, while ironically commenting on the lack of opportunities for local medical students. Then there are the “professional conference attendees” who hop from country to country without ever actually discussing and solving issues of global health importance. This is not what global health should be about.

As someone from the global south questioning the intentions of global health academics and volunteers from the global north, it’s easy to feel like you risk sounding whiny and ungrateful. But perhaps this is also a learnt inhibition from years of being pushed to the back of the room.

To many people, it may be surprising to know that medical missions and global health has its origins in colonization efforts and medical missionary work. Today’s short term volunteering opportunities or programs in LMICs offer the chance to build CVs, have an adventure trip, create experiences, and feel good about oneself. That students are seeking these goals is not necessarily bad in itself. However, if these experiences are not inclusive of mutual respect and if they pull the curtain over the true state of local communities, they risk becoming another toxic chapter in our colonial history. 

In a world of huge divisions and inequity pervading every aspect of life, we need better accountability and fairer practices from those who have benefited from the systemic colonial mindset of global health.

Based on personal experiences and opinions from LMIC colleagues, here is what you could do instead: 

  1. If you are a student from a HIC visiting a LMIC for research, volunteering, or a medical mission, respect the local culture, make efforts to learn the local language, and be considerate of the local system in place. Don’t do anything that you would think twice before doing in your own country. Your environment may change, but ethical principles are universal.
  2. As an institution organizing global health volunteerism, you should conduct pre-departure training on ethical scenarios, culture shock, and respecting the privacy and confidentiality of people.
  3. If you are an institution offering global health courses, make it affordable for individuals from LMICs. Support them by offering grants, reducing costs for LMIC applicants, or, most importantly, creating an online, distance learning version of the course at a lower price for LMIC students. 
  4. As a conference organizer or member of an academic society, ensure that conferences on global health issues are held in countries where it is relevant and where local experts can attend without encountering visa or financial difficulties. Holding a TB conference in a Nordic country that experts from regions with a high burden of TB cannot afford to travel to is pointless. Even within the LMICs, make these conferences affordable and accessible to health workers on the frontlines. 
  5. Give equal representation to LMIC experts as board members for global health organizations and on editorial boards of global health journals. Make these journals accessible to LMIC institutions and offer platforms for local experts to share their voices. These organizations are not truly global if their leadership is not inclusive. 
  6. Actively include and engage local healthcare workers and volunteers. Seek their opinions and consider their advice. They know more about what will work for them than those who have sat in the air conditioned classrooms of London and New York.
  7. Ensure that your program benefits local communities and not just visiting scholars or HIC institutions. Measure the program’s impact, evaluate your progress, monitor the trends, and seek feedback from local partners. 
  8. Change the language and hierarchical culture of “provider-recipient” to “partners.” Mutual respect and equal partnership goes a long way in establishing trust and enhancing progress. 
  9. As an organization that arranges volunteering, change the practice of short term medical missions to instead  focus on training and imparting skills to local healthcare workers. This will ensure the sustainability and long term success of projects. 
  10. If you are in a position of power or influence, use your voice to raise the concerns of those who are not heard or who cannot do so themselves. Advocate for global health equity at conferences, write about it, and use social media popularity for wider good. 

Subtle inequities pervade every sphere of global health, and in many ways the turmoil caused by this year’s pandemic has put them under the spotlight even more. However, the covid-19 pandemic has also opened up new opportunities to bridge the gap. The unplanned, yet welcome, shift to conferences and courses taking place online has helped experts from limited resource settings offer their expertise and gain new knowledge without worrying about financial issues constraining their attendance. I’ve also observed what seems like a greater number of collaborative studies offering equal authorship opportunities. 

That being said, we still have a way to go to reach global health equity. Courses and conferences, even if online, are still too expensive for far too many students and professionals from lower resource settings. The voices we hear in global debates are still mainly from privileged socioeconomic backgrounds, with far too little being heard from the most disadvantaged communities. The pandemic has also halted, and in many instances reversed, progress made in global health over decades. 

It may take some time for things to get back to the pre-pandemic situation, but this reality also means that those working in global health have more scope to create better opportunities and a level playing field for students, researchers, and healthcare workers from LMICs. Steering global health in a new direction, in which we don’t repeat the same mistakes of the colonial past, could be the biggest lesson we learn from the pandemic.

Ankit Raj is a global surgery fellow at the WHO Collaborating Centre on surgical care research in LMICs in Mumbai. He is currently studying international relations and diplomacy at the Indian Institute of Governance and Leadership, New Delhi.

Competing interests: None declared.