Everyone has once been found guilty for using these words. Developing countries, third world countries, poor countries, and more. Terminology so embedded in academia and international affairs, yet so full of stigma. Systemic violence is apparent throughout global health and often expresses itself in the way we express global health. Language defines how we, as individuals and societies, perceive the world around us. Words chosen in one culture or language will differ from those used by others, underlining the intricacies of societal complexity. Yet, specific wording not uncommonly brings with it negative connotations, which intentionally or unintentionally reflect our way of thinking.
Outdated terms used to describe the so-called “first world” and “third world” countries were once taken over from political designations defining countries during the Cold War. Countries aligning with the North Atlantic Treaty Organization (NATO) were designated as “First World” countries, whereas those supporting the Soviet Union (“Second World”) and those unrelated to the Cold War (“Third World”) were deemed otherwise. Ironically, over time, the ubiquitous “Third World” terminology grew to become a common, but harmful description of countries struck with widespread poverty.
In a similar manner, the use of “developing country” to describe countries in the midst of demographic transition and socioeconomic growth has wrongfully forged a harmful spectrum of designations to separate “Western countries” from “Southern countries”. In reality, especially in global health, there is a fine line between both, often inverted when digging deeper. For example, the United States is not safeguarded from healthcare system deficiencies: for one, rural areas are faced with large disparities in access to surgical care (e.g., a pregnant woman having to drive four hours to reach the nearest facility to give birth with skilled attendance and obstetric care) and even primary care. Additionally, the lack of comprehensive health insurance coverage and financial catastrophe suffered by hundreds of thousands of individuals to receive life-saving or life-changing care is what one would typically ascribe to a so-called “developing country”.
Not to mention the use of “low-resource countries”, often to describe countries laden with fertile grounds, leading export of coffee beans and tea leaves, burgeoning with diamond and gold mines – ironically, these constitute the countries with the lowest gross domestic products (GDPs) per capita. If nineteenth and twentieth century (and, arguably, persisting twenty-first century) colonialism did not wreak havoc on these countries’ natural resources and political climates, would North America and Europe be considered “low-resource”?
Global South and Global North do not make things better but are often used as “less harmful” surrogates for the above terminology. And yet, they try to homogenize largely heterogeneous regions to an extent that is descriptively inaccurate by all accounts. It further implies that geography is the main driver of what makes a country prosper, in a similar manner that “the West” unintentionally describes. Is your country in Europe? You are set to flourish. Located in the Southern Hemisphere? Bad news. Interestingly, when we look at examples of social inequality in “the Global North” or “the West”, such as lower-income neighbourhoods in Glasgow and Baltimore as vividly described by Sir Michael Marmot in The Health Gap, we see little difference with the bottom quartile of countries by life expectancy. In fact, many countries in the “Global South” (e.g., Chile and Costa Rica) have reached life expectancies similar to or higher than those of countries in the “Global North” (e.g., the United States and Luxembourg).
Adhering to this terminology upholds a colonial train of thought. If describing a country as “Third World”, “developing”, or “low-resource”, regardless of one’s good intentions, we sustain an imaginary distinction between seemingly “superior” and “inferior” countries. These words carry the connotation that these countries are poor, dismantled, undeveloped, and will always be so. These words do not bolster change and progress, and undermine the successes achieved in recent decades by countries all around the world. What’s more, these classifications make little geographical sense. The United Nations’ Human Development Index (HDI) ranking, a measure combining healthy life expectancy, educational opportunities, and the standard of living, may coalesce countries on both extremes in common regions, but the middle half does not adhere to the above heuristics.
Where the HDI ranking is not without flaws, defining countries by the World Bank’s income group classification (based on countries’ GDP per capita) is arguably the most neutral way of describing countries, if a distinction based purely on socioeconomic growth has to be made. High-, middle-, and low-income countries, although with geographically skewed trends, are scattered throughout the world with gross heterogeneity in terms of resources and politico-military history. No terminology will arguably ever be perfect, but the objectivity and benchmarking thereof leaves little ambiguity or neo-colonialism to its imagination.
With dramatic gains in health measures in recent decades around the world, many low- and middle-income countries have made great strides in HDI. Reduced deaths due to infectious diseases, elimination of polio and increasing containment of HIV/AIDS, improved clean drinking water and sanitation, increased healthcare financing and development assistance for health, and expansive child education have all resulted in significant surges of life expectancy and socioeconomic growth. Meanwhile, high-income countries may be faced with market-based health systems, decreases in vaccine utilization, widespread non-communicable diseases, and mental health impediments. What was once considered a distinctive line is now a continuum, and one to be traversed.
In an ideal future, every country’s development index and economic prowess slowly converge despite every nation’s unique culture, resource availability, and geographical determinants, but that may never be so. Upholding an artificial, post-colonial divergence based on outdated monikers, however, threatens to impede progress towards equal opportunities and empowerment of countries to climb up the human development ladder.
About the author
Dominique Vervoort, MD is a Belgian physician and MPH/MBA dual degree student at the Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Carey Business School, and previously completed the Paul Farmer Global Surgery Fellowship at Harvard Medical School. Twitter @DVervoort94
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.