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The practice and vocabulary of global health and global development today have their origins in racism and colonialism, which has created a false hierarchy among nations, ascribed a higher value to some lives, and allowed some groups to extract, exploit and subjugate others.1–4
The persistent echoes of these origins are seen everywhere, particularly in the way we use terms that classify countries and people: rich versus poor nations; resource-rich versus resource-limited settings; First versus Third World; Old versus New World; developed versus developing countries; high-income countries (HICs) versus low/middle-income countries (LMICs); global North versus global South; beneficiaries versus donors; white versus Black Indigenous and People of Color (BIPOC) and so on (see Table 1).
The terms ‘global’ or its much-used counterpart ‘international’ imply a world outside rich nations (often seen as the epicentre of everything progressive and ‘good’); a world which needs development or health assistance. The fact that these implicit connotations are largely unchallenged in most global health and global development institutions in HICs itself is worrisome and illustrates how both these sectors continue to be steeped in white supremacy and saviorism.2 Even terms originally coined without a connotation of hierarchy, such as global North versus global South (or West vs East), end up implying hierarchies given these divisions are based on access to wealth and political power.
Why do words matter?
The temptation to categorise and dichotomise is very powerful and pervasive. All of us have used some of these terms at some point in our professions and activities. Some terms such as the now defunct ‘First World vs Third World’ imply racism in terms of hierarchy; the notion that some are first and others behind.5 Most people today avoid them, but Western media for instance, continue to use them every now and then, as we have seen most recently during the coverage of the Ukraine war, or the COVID-19 pandemic. The idea that countries are inherently different, ordered or ranked along a hierarchy is a racist, colonialist construct. But one thing is clear—all these terms have their origin in European and North American institutions and structures (see table 1).
Some terms are based on economic classifications driven by groups such as the International Monetary Fund and World Bank for purposes of lending. But such lending efforts have served to perpetuate these hierarchies; maintaining one group as donors and others as recipients.6–8 By extension, the aid industry, abetted by international financial institutions, bilateral and multilateral institutions and international non-governmental organizations (NGOs), has further created dichotomies which amplify these hierarchies in terms of aid providers/donors and receivers.3 4 9 Beneficiaries are those beholden to the priorities and conditions of aid institutions, while donors/providers are perceived as white saviours.4 9 We continue to see this play out during the COVID-19 pandemic, with inequitable/insufficient vaccine donations and the power dynamics that prevent more countries from manufacturing their own vaccines and medicines.10
Classifying countries in terms of income or human capacity/skill also ignores why some countries have become ‘high income/high-skill’ or ‘resource-rich’ while others remain ‘low income/low-skill’ or ‘resource-limited’. Have the latter been intentionally kept resource-limited by the former? Is it the effect of colonisation? Why do not we speak of extraction of capital and human resources? Why do not we speak of exploitation and reparations? Why do not we speak in terms of former coloniser versus decolonising countries or exploiter versus exploited countries? Why should anyone expect that people from supposedly ‘low income, low-skill, low-resource’ countries—most of which are currently recovering from colonisation/exploitation—be happy to see their countries described using such terms?
Dichotomies create the sense of an inherent hierarchy between countries and regions. But they can also reinforce a sense of superiority among those whom the language implies are superior, and a sense of inferiority among those assigned the mantle of negative or othering descriptors. The racial implications of such hierarchies are also at play when white is the reference category and everyone else is lumped as ‘another group’ such as Black, Indigenous and People of Color or BIPOC. Lumping diverse people into such broad groups ignores the different cultures, histories and origins of communities around the world. Black and Brown (the latter not represented in the BIPOC acronym itself) groups, for instance, are each distinct from Indigenous groups, especially within settler colonial countries.
Dichotomies also pit countries against each other. In the North/developed/advanced/HIC/rich category, countries compete with each other to gain the most control—as the largest ‘donor’ or aid provider, or the donor with most influence on agenda setting. In the opposite dichotomy, countries vie to obtain the largest piece of the pie, that is, who gets the most money? Who is the biggest aid ‘receiver’? It creates an unnecessary sense of rivalry or competition between countries who should be working together to address an issue. Even the dichotomy of ‘global health’ versus ‘global development’ needs discussion. While global health is now seen as a stand-alone sector, it is very much just one part of the overall global development sector which has been heavily impacted by the politics of aid. It is important not to create such a distinction between the two. After all, health also encompasses and is impacted by other variables such as income, access to education, housing, gender equality and even justice.
Countries that deem themselves superior are also unable to, indeed, they do not want to learn from others, as seen during the COVID-19 pandemic.11 Capacity or lack thereof is assumed; so global South countries and organisations are often seen as in need of capacity strengthening while those in the North are assumed to have capacity regardless of the issue. For example, although African institutions have tremendous expertise in dealing with malaria, large-scale malaria funding often goes to HIC institutions as primary recipients.12 In development, NGOs based in HICs design, implement, manage and evaluate programmes in LMICs. This includes ‘capacity-building’ programmes where the capacity of non-white people is ‘strengthened’ by white people.13 Dichotomising language perpetuates a situation in which scholars, health professionals, development practitioners and activists are recognised not by their knowledge, but by where these terms place them geographically, economically and historically.
The fact that the world has failed on COVID-19 vaccine equity suggests that we are still unable to see ourselves as part of one large family called humankind, regardless of our nationality, wealth or skin colour. Self-centered and nationalistic response to pandemics, wars and the climate crisis reflect a failure to see beyond narrow national, racial or economic boundaries.14 Development efforts are still unidirectional. Knowledge, and resources (financial and human) still flow from North to South, mimicking colonial times.15 16 This plays out in the COVID-19 response, even though several rich countries with ‘strong health systems’ struggled to contain the virus, while lower-income countries with ‘weak health systems’ fared the same or even better.11 Global solidarity demands a more equitable, non-hierarchical and inclusive engagement of all nations and partners, working synergistically, learning from one another, to tackle major crises.
What is the way forward?
The terminology used to divide the world into the haves and the have nots has continually changed since colonial times to reflect the changing political and social environment. But every new term continues to imply and allude to an inherent unevenness. There is no denying that glaring inequality between countries does exist. But bolstered by such terminology, invariably coined by only one part of the world, we are not acknowledging sovereign states and their independent identities. It also points heavily towards how colonialism has influenced how countries view each other.15
So, what can we do to bridge these referential inequalities? Simply putting a stop to their use is not as simple as it sounds. For instance, many of us use terms like LMICs and Global South as a way to point out these exact inequities in health and development. We could, for example, write that tuberculosis primarily affects LMICs. Or we could individually list out the 30 countries where the disease burden is very high. That is not practical. Likewise, we could state that poverty is on the rise in say 50 odd countries of the world, but has been reduced in about 20. This is neither easy nor feasible when we write or speak. So, we do need terms to communicate that are simpler.
But how can we do this without further entrenching false dichotomies and divisions that are now driving the objectives of global health and development? We provide some imperfect suggestions below, and hope this article will provoke a discussion that will generate other suggestions.
We could recognise the unique geographical distinctions that define our globe. Africa, for instance, contains five distinct regions—West, East, North, Southern and Central. Likewise, Asia is divided culturally and ethnically, into the Middle East, South Asia and South-East Asia. Latin America is comprised of Central and South America. The Caribbean states and Pacific Island nations hold their own individual geographical identities. While each of these regions contains distinct national identities, cultures, languages and histories, they are at least cognizant of some sense of collective identity.
More recently, there has been a suggestion to use the term, ‘Walled World’, which illustrates how 14% of the world’s population hides behind a fortress or a wall which denies entry to the world outside it based on wealth.17 This is clear from the physical walls that have come up across the world such as in the Palestinian Occupied Territories and even Trump’s ‘border wall’ between Mexico and the USA. It also signifies the political barriers created by for instance, ‘Fortress Europe’ to keep migrants and refugees from entering the continent.
Instead of automatically equating low-resource or resource-limited settings to LMICs,18 we could be more specific about why and how a setting is low-resource and along which dimension. For example, is it low resource in financial terms or in terms of knowledge infrastructure, human resources, physical infrastructure, service delivery or geography18—and what are the historical underpinnings of such a resource status? This way, we make it clear that there are low-resource or resource-limited settings in essentially every country, including the richest nations. Such nuanced categorisation opens space for richer discussions that go beyond the dichotomy of some being low or limited resource and others not. It opens the possibility of digging deeper to explain why a setting is low resource and another is not. It also means that the low-resource or limited-resource category can shift depending on the issue under discussion.
We can clearly discourage some terms, and perhaps use others with caveats. For instance, First World versus Third World and developed versus developing countries are clearly ambiguous and have racist connotations. Using income as a source of distinction may be more useful, especially when it provides some insights behind the economic and social variables that define a country’s needs—and if it highlights nuances within countries. For example, Rosling’s categorisation of four income levels is more granular than dichotomous, and classifies people instead of countries.19
Terms such as BIPOC or people of colour clearly denote that they are not being seeing as having distinct characteristics or origins—and suggest that white people are without colour. It may be more appropriate to refer to people by their individual ancestry, for example, Northern European, West African, East Asian, South Asian, Middle Eastern, etc—or by their countries or ethnicities.
In the development context, there has been much said about the use of terms such as aid givers and receivers; donors and beneficiaries etc. But this requires the entire aid industry to reflect on its own role in the world. Simply replacing these terms is not adequate and will not change the industry’s ways. The industry’s intentions, methodologies and practices must also change.3 9 Initiatives such as Decolonise Medecins Sans Frontieres (MSF) are charting a path towards this.20
The way we classify countries and people highlights a contentious problem that does not lend itself to a simple solution; an issue which people can rightly approach from different standpoints. This means acknowledging the situatedness of some terms, and how while some of them may be relevant and make sense within certain spaces or movements or political realities, they do not travel easily. Simply coming up with alternatives may not be a solution—alternatives may continue to exclude or other. It is difficult, if not impossible, to have a global standard for how we use language to describe differences and categories. It is not possible to find a name or term that resonates with everyone or speak to everyone’s needs and preferences given our inevitably differing valid positionalities. Our choice will often depend on our goals, whom we are in conversation with, and what we are trying to achieve. But perhaps we should also consider that every region is entitled to create its own standards based on its specific understanding of health and development. That might be a worthwhile starting point.
Everyone in global health and global development (that includes us!) must be thoughtful about the terms we use on a daily basis, and understand their origins, meanings, and do our best to resist oversimplified dichotomies, and instead use nuanced terms that recognise the vast variations among countries and people, and respect how people want to be described.
Data availability statement
There are no data in this work.
Patient consent for publication
We are grateful to Julia Robinson for her feedback and input.
Twitter @themrise, @seyeabimbola, @CKyobutungi, @paimadhu
Contributors TK and MP wrote the initial draft. SA and CK contributed to further developing the ideas in the initial draft. All authors revised and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.
Competing interests SA is Editor in Chief of BMJ Global Health and MP serves on the editorial board. CK and MP are Editors in Chief of PLOS Global Public Health. SA is a Section Editor of PLOS Global Public Health.
Provenance and peer review Commissioned; internally peer reviewed.
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