In the sixth seminar of the Lancet Commission on Gender and Global Health series, the spotlight fell on Commission co-chair Pascale Allotey, Director of the United Nations University International Institute for Global Health (UNU-IIGH). Pascale was joined by fellow Commissioners, the Co-Chairs and a public audience joining via YouTube live stream, to discuss gender equality and decoloniality in global health.
Inequity in a time of pandemic: The dilemma of the Commission
The pandemic has sharply exposed existing social fractures and inequalities, and in doing so has catalyzed calls for radical social change. Pascale proposed that there are two parallel conversations that have gained momentum in the context of equity and global health which are pertinent to the work of the Commission:
- The default approaches and tools of global health may now have limited utility. There is a desperate need for creativity and an openness to different types and sources of evidence that are better able to interrogate the complexities of today’s challenges and produce effective, equitable solutions.
- There is an increasingly irrepressible voice demanding that we address the inequities that impact on health and wellbeing. These voices must be amplified and given space, or else the Commission risks being culpable in enabling and exacerbating inequities.
For Pascale, these two conversations reveal a fundamental dilemma that lies at the heart of the Commission.
The Commission is tasked with tackling gender inequities in global health. Collectively, the Commissioners are committed to drawing on existing scholarship as a springboard to develop future-orientated recommendations that envision a world in which gender equality is evident in outcomes for health and wellbeing. However, the process is bound by the disciplinary limitations of global health and the Commission’s cumulative output.
Global health, Pascale reminds us, is a discipline borne from the medical and health sciences, which fundamentally operate from a positivist, reductionist standpoint. The methodologies and practices of social and political sciences may have gained some precedence, but still remain secondary to the ‘real evidence’ that is valued in the field. The output of the process, a report targeted at the Lancet health audience, is, in turn, expected to fit into a paradigm that recognises and embraces this solipsism in order to be robust, structured and objective.
But the inequities that the Commission seek to address are not in the realm of the clear, tangible, positivist and reductionist. Gender and other inequities are rooted in our cultures, our systems and in what or whom is considered important and valuable. Inequities do not conform to a disease model where the diagnosis delivers the solution. Such a model can provide evidence for the investment in disease but not in the production of health and wellbeing, so what is the alternative?
Decolonisation in global health discourse
Decolonial movements draw on the emotiveness of deep seated inequities, and highlight the inability of global health as it is currently defined and implemented to address them. Decolonisation calls for a breaking down and reversal of the injustices and impacts of colonialism and neo-colonialism, the systems at the origin of today’s injustices.
There are extensive bodies of work on decolonisation in ethics, politics, sociology and philosophy that date back to the 1930s, and yet, these ideas are relatively new in global health. In order to assess the growth of decolonisation in global health literature and to understand who is writing and thinking about the issue, Pascale’s team have been monitoring decolonisation in global health literature published since 2000. Dr Emma Rhule presented a review of what they found (Rhule and Allotey, in prep).
Interest in decolonising global health has increased dramatically, particularly over the past two years. The team wanted to understand where in the world the drive to decolonise global health is coming from. To do so, they identified the institutional affiliation of the first and last authors on the papers arguing that association with powerful global health actors in the global north gives these authors a voice and influence in the debate that colleagues situated in the global south often lack.
Strikingly, just 14% of first authors were affiliated with institutions situated in countries in the Global South, representing the depressingly small percentage of published thought leadership from the region. The same pattern emerges in the affiliation of last authors, typically most senior in global health writing, of which just 20% are from the Global South. Taken together, the data suggest that there is a risk that the decolonisation narrative is, itself, being colonised.
Next, Emma turned to the content of the papers- now that we know who is writing and from where, what are they saying?
Emma divided the papers into the three main pillars of global health:
- Knowledge production- who is doing the research, on what, from where and how is it being prioritised?
- Dissemination of research e.g. in publishing and conferences- who gets to control the narrative, what are they privileging, and what voices are missing?
- Funding- who is paying and what are they buying?
The review reveals that the majority of conversations on decolonisation are on knowledge production, focusing on the problem of colonialism’s injustices and the ideas that underpin decolonisation. The papers that do tackle decolonisation in application, are primarily focused on decolonising education and cover areas including the content of curricula and methods of teaching. Only 2 papers on decolonisation’s implications for policy were identified, both of which were from settler colonies- Australia and New Zealand. There are only a handful of papers that offer more practical ways to decolonise including diverting funds to organisations, decolonising methodologies and engagement with communities. And, only one letter to the Editor of the Lancet, a mere 256 words, addressed the need for an accountability framework to decolonise global health.
Emma concluded that there is a plethora of papers that identify what the problem is, but a scarcity of papers that offer solutions. We are pushing for change, but who is keeping track of that change and who are we being held accountable to?
Pascale further elucidated a series of ideas for the Commission to explore based on the findings of the review:
- If funding models are a part of the problem- what is the solution? Given the power of resources, is there a world where recipients from the Global South can dictate the conditions under which they are paid to accept resources?
- There are funders that have made changes to account for the need for locally driven solutions - is this the decolonise model that we’re looking for? And if so, are there best practices?
- There are multiple agreements about ethical partnerships and respectful engagement, but how is anyone or any institution being held to account?
What does successful decolonisation look like?
So, what does successful decolonisation look like? Who is required to deliver it? And how can they be held responsible?
In order to answer these questions, Pascale instructs us to first address a set of more provocative questions. Namely, what is the crux of the injustice of colonisation? What do we want to see reversed? How can we begin to right the wrongs? How do issues of gender, race and other inequities intersect with decolonisation and how do we draw these agendas together towards a just and equitable global health without creating competing vulnerabilities?
The decolonisation agenda is a call to recognise past injustices, the impact of which have persisted. If we think of colonisation as primarily the domination of peoples and communities and the discrediting and destruction of civilisations, cultures, and ways of life, decolonisation needs to be a project of reversal, Pascale argues. We cannot unlearn what has brought us to where we are today, but we can engage in a process of re-humanising which requires us to be reflective of our positionality - who we are and what we bring to particular discussions. As Pascale asserts, we need to question who are the right people to hold this conversation because who is at the table makes a difference.
A decolonisation agenda requires us to explore the range of reparations required for healing, which involves both a recognition of wrongdoing and empathy, as well as a preparedness to give up power and resources. As Pascale emphatically iterated, people have to give up something for equity to be achieved, it’s not necessarily a zero sum game.
Implications for the Commission
Pascale closed by reminding the Commission of the enormity of the task of redressing gender equity and gender justice in health. She called upon fellow Commissioners to go beyond the limits of global health and to enter into a dialogical learning process for solutions that could enable sustainable change beyond the end of the project.
For Pascale, decoloniality provides an opportunity for reversal and a space to privilege the suppressed and devalued ways of being and thinking that acknowledges the plurality of voices and plurality of evidence. But decoloniality requires a willingness to listen and be open to a world in which consultation brings different people to the table, and also requires others to remove their seat. It requires that the Commission push for investments into its engagement with communities and with each other that acknowledges historical domination, disempowerment and disrespect. It requires an acknowledgement that who we are is an embodiment of cultures and societies that have either been abused or were abusers and continue to be so through policial, social, cultural and structural processes. Quite a task indeed.
You can watch the full online seminar here.