Why and for whom are we decolonising global health?

The growing calls to decolonise global health are welcome but also worrisome. Suggestions for decolonisation vary greatly, with a common view to shift power to local ownership but without clear plans on how to make this suggestion a reality. Many researchers are calling for global health research to be led by local leaders in low-income and middle-income countries (LMICs), with expatriate academics providing peripheral support rather than the other way around.1Costello A Zumla A Moving to research partnerships in developing countries.BMJ. 2000; 321: 827-829Crossref PubMed Scopus (223) Google Scholar Others call for radical transformation as the only reasonable response to addressing the complexity of reforming global health research when many leaders in global health have built their careers in institutions that advance and sustain white supremacy.2Hirsch LA Is it possible to decolonise global health institutions?.Lancet. 2021; 397: 189-190Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Abimbola S Pai M Will global health survive its decolonisation?.Lancet. 2020; 396: 1627-1628Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar Global health institutions, researchers, and priorities are predominantly in high-income countries (HICs), whereas the bulk of the research work and intervention programmes are implemented in LMICs. Commendable gains have been made in addressing global health issues, such as treatment for people living with HIV, but wholesome improvement of the health-care system of LMICs is often minimal or non-existent, highlighting the priorities of HICs and dependency on donor programmes. The push to decolonise global health and the resultant conversations are, unsurprisingly, taking place primarily among academics based in HICs, and LMIC participation is limited to researchers who have built their careers within the current colonial global health structure. Perhaps there is something to learn from the process of political decolonisation in countries like Kenya. Colonial powers, facing the inevitability of granting independence to colonies, were intentional in leaving power in the hands of local leaders sympathetic to the European outlook: western-educated descendants of paramount chiefs appointed and propped up by the colonial regime in largely acephalous communities, or people in LMICs who had converted to Christianity and had an education—factors which often were conjoined. These colonially appointed and backed local leaders were also the beneficiaries of the Africanisation of the colonial civil service. In political decolonisation, leaders in LMICs have sustained the same political and socioeconomic structures carved by colonial governments, resulting in a relationship of dependence, neocolonialism, and an ever-widening gap between the rich and the poor. Akin to this transition in political leadership, dominant global health institutions, through education and leadership positions, have produced researchers educated to HIC standards from LMICs who are replete with skills to work within the current global health system, sustaining their power structures in the process. The call to diversify global health leadership, if done within the current structures, runs the risk of repeating the same decolonising mistakes. Even if global health research priorities were set by academics in LMICs, closer examination of the relationship between global health researchers from HICs and those from LMICs shows the situation to be direr: research grants for projects in LMICs are channelled through researchers and institutions in HICs; researchers in LMICs have not had the resources at the disposal of their counterparts in HICs, such as protected time, grant teams, advanced laboratory infrastructure, and postgraduate trainees from around the world to work with. Asking leaders from LMICs to take up positions within the current structures without acknowledging the entire systems made to support careers of researchers in HICs would be but a cosmetic change. True transfer of power and equitable partnerships will require investing as much time into rebuilding research infrastructure from the ground up in LMICs as is done in supporting individual careers of global health researchers in LMICs. Similarly, we need to pause and ask whether ordinary citizens in LMICs, struggling under a system bearing colonial legacy in multiple spheres of their lives, are participants in this discourse, and whether their participation in challenging this system can be through “rational confrontation of points of view”4Fanon F The Wretched of the Earth. Penguin Classics, London2001: 31Google Scholar in journals based in HICs. The ordinary citizen will probably prioritise comprehensive health care—a stark contrast to the long history of studying tropical diseases. When goals of local global health researchers uphold those of researchers in HICs, will diversifying global health leadership address the plight of citizens in LMICs? The fragile health-care system in LMICs is a simple proxy for equity and justice in global health. Lastly, decolonising global health cannot be complete without examining the socioeconomic and political context. The structure and objectives of research and collaborations in global health must be decolonised to address the whole spectrum of health determinants. We declare no competing interests.