The origins and nature of feudalism in global health

European colonisers manoeuvred existing social hierarchies in colonised nations into varying types of feudal structures to sustain imperialism.10 Broadly, the model consisted of elites in colonised nations being co-opted by colonisers, given proprietary right of land, produce and people, together with the implicit right to exploit. An example of such colonial feudal administrative structure is the ‘Zamindari’ (land holder) system in British India. ‘Zamindars’ were economic and social elites given the right to collect rent from peasants in return for an annual fee to the ‘Crown’. Owing to their intermediary role, they were in a unique position to maximise their income and scope to expand their land holdings but had no pecuniary interest in developing the land. Through these intermediaries Britain controlled India—a large nation, with diverse cultures and values—for centuries.11

During the colonial period, health facilities were developed in colonised nations with the primary intent of protecting the bureaucracy and military which were needed to sustain the political and economic system.12 13 However, all the apex health organisations and knowledge institutions were based in Europe. During this period, there was seamless movement between colonised and colonising countries which necessitated and provided the means to develop the field of tropical medicine and international health.12

After gaining political freedom, erstwhile colonies embraced continued free movement of knowledge. In the changed circumstances, the ecosystem metamorphosed into a new feudal structure. A small group of multilateral entities and HIC universities evolved into what we see as the ‘Crown’ which controls the global health (knowledge and practice) ecosystem.14 Academics and practitioners based in HICs (ie, the new Zamindars of global health) working in and for those institutions continued to have seamless access to erstwhile colonies, but the premise on which they operated had changed. The old colonial Zamindars were based in LMICs; but the new global health Zamindars are in HICs. Social and geographical disconnect between the realm of action and the realm of power is the true essence of colonisation. In the current global health ecosystem, actors can broadly be classified under the following categories:

• Located in HICs, with their realm of action predominantly being HICs. Their interaction with global health ecosystem is primarily technical/methodological.

• Located in LMICs, with their realm of action predominantly being LMICs. Their primary portfolio and zone of influence is their respective LMIC. Most do not see themselves as ‘global health’ actors. Their interaction with global health ecosystem is primarily on technical or regional issues, and when ‘global health’ actors based in HICs seek to engage with them as part of international health partnerships.

• Located in HICs, but their realm of action is predominantly LMICs. They primarily enhance their portfolio of work in LMICs but are answerable to the ‘Crown’.

It is this third group of actors—academics, practitioners and institutions based in HICs—who in our framing, act as the feudal lords or ‘Zamindars’ of global health. They dominate over issue domains, in a certain foreign geographical region. Their influence (if not control) on global, national and subnational priorities, policies and resourcing are operationalised through this feudal structure. This enables continued Euro-American hegemony over knowledge ecosystems. Feudalism is justified through narratives on lack of ‘technical skills’ or ‘subject matter expertise’ and promoting monotheism in epistemology and ontology.5 Feudalism is further strengthened by neo-colonial economic systems which provide leverage to HICs over LMICs. To make progress, efforts to decolonise global health must first acknowledge this feudal structure of contemporary global health.

Addressing feudalism in global health

Although DEI efforts within existing ‘global institutions’ are essential to address inequities, they do not dismantle the feudal structure which enables colonisation.15 On the contrary, DEI efforts grant ‘Crown’ organisations and institutions in HICs legitimacy. To break the feudal structure of global health, the multitude of global health actors16 needs to take cognisance of their positionality within the ecosystem. Structural power imbalances between nations, within nations, and among different actors in the feudal system should take the front seat in efforts to decolonise global health. These efforts should continue to harvest learning from the parallel but separate movement to end structural racism globally.

Transnational global health actors have an overarching role to end cultural, economic and psychological colonisation17: culturally, by ensuring that the development of methods and methodological standards are led by LMIC actors and are reflective of local realities; economically, by ensuring direct funding to LMIC institutions without intermediary (or accompanying) feudal lords; and psychologically, by giving greater accord to the knowledge and technical skills of those on the ground over parachuting feudal lords. On the other hand, LMIC governments must improve the ease of doing science—that is, invest in research, remove techno-legal barriers, increase funding opportunities for citizens, build research capacities and strengthen local knowledge systems for health.

Due to their unique position in the ecosystem, feudal lords themselves are well placed to contribute towards dismantling feudalism. It is no co-incidence that many leaders of political decolonisation movements were people who gave up assured comforts within the colonial political ecosystem to fight for decolonisation. Feudal lords in global health can significantly contribute to the decolonising movement, if they resolve their moral tussle of being ‘double agents’18 and harvest their network, influence, and intellect to prevent subjugation of individuals and institutions in LMICs. Actors in LMICs also need to engage more intensively in the global health ecosystem. LMIC actors can start by claiming their rightful leadership of the current movement to decolonise global health.