Decolonising global health in the Global South by the Global South: turning the lens inward

Introduction

“Decolonization, as we know, is a historical process: that is to say that it cannot be understood, it cannot become intelligible nor clear to itself except in the exact measure that we can discern the movements which give it historical form and content.” – Frantz Fanon, The Wretched of the Earth1

‘Decolonisation’ has been the buzz word in Global Health for the last few years. It aims, and rightly so, to challenge and dismantle historical and ongoing power imbalances, inequities and colonial legacies within the field of global health (table 1).2 3 The end goal of decolonisation is more equitable, inclusive and just approaches to addressing global health challenges, where communities and nations of Indigenous people and the Global South have control and ownership over their own health research, research products and agendas.

However, the ongoing decolonisation narrative has largely focused on colonial and neocolonial practices of the Global North and how its people and institutions exert control and influence over health policies, research agendas, funding priorities, publications and interventions in low- and middle-income countries (LMICs), while disregarding Global South knowledge systems and community priorities.4–7 Proposed decolonisation solutions have followed the dominant narrative and mainly address coloniality of the Global North at the Global North-South interface (figure 1). While global health experts in the Global South have had to agitate for equitable recognition, participation and leadership,8 9 we are not exempt from scrutiny when it comes to perpetuating coloniality in this field.

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Turning the lens inward

The authors write this piece as a Global South-based global surgery researcher, educator and practitioner in India (DS), and as a Global South-based global health researcher, educator and practitioner in West Africa (NAS-A). We have attempted to write this outside of the foreign gaze; our pose and the gaze we write for is the Global South.10

We have observed that there is relatively little depiction of the Global South’s role in perpetuating coloniality and of its responsibilities in promoting decolonisation within its own geography. While the impact of colonisation, coloniality and neocolonisation from the Global North is appropriately a major focus, it is not sufficient to fully achieve the aspirations for decolonisation in global health.2–4 We, the Global South, appear to be waiting somewhat passively for the rising tide of decolonisation initiatives from the Global North to lift all boats, rather than actively partnering in, or leading the process. Individuals, communities and countries in the Global South need to turn the lens of decolonisation inward and scrutinise their own errors of omission and commission at the ‘local Global South’ level (figure 1).3

Granted, resource constraints in LMICs of the Global South can hamper decolonsation initiatives and limit sustainment. However, we believe that major reasons for the paucity of ‘local Global South’ discussion and action on decolonisation are that (1) we have not educated ourselves appropriately on the ‘what’ and ‘why’ of decolonisation for our purpose and (2) we have not done enough introspection into our roles in perpetuating coloniality in global health in the postcolonial era. Decolonisation responsibilities for Global South personnel working in global health research, education or practice are not trivial and are worth considering for action, because (1) Global North-led initiatives will be more likely to be pragmatic and uphold the status quo11 and (2) Global South-led initiatives promote Global South ownership, which is more likely to drive aspirations that bring about fundamental change.2 12

From industry, we borrow the Four Actions Framework,13 which guides business organisations to identify and address internal bottlenecks to optimising product innovation, value and affordability. For this paper, we consider decolonisation the ideal ‘product’, and the ‘internal bottlenecks’ are coloniality of thinking and actions in global health by the Global South within its own ‘organisation’. We then pose introspective questions to the Global South to address for local-level decolonisation according to the Four Actions Framework’s Eliminate-Reduce-Raise-Create grid (figure 2):

• Eliminate: What individual behaviours and actions need to be removed completely?

• Reduce: What systemic inequities and practices need to be minimised?

• Raise: What neglected knowledge/knowledge systems, people and infrastructure need to be platformed, elevated, strengthened or scaled up in global health epistemology (the creation and study of knowledge) and ontology (the realities and study of being)?

• Create: What previously unavailable or nonexistent decolonised knowledge needs to be widely disseminated or developed de novo?

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If these questions raise discomfort, we clarify that they are not posed as an inquisition. Rather, they are a call to the Global South to be introspective, to recognise its role in coloniality, and to take responsibility for its part in the process of decolonisation in global health.

Conclusion

We recognise from our own experiences that the centre of gravity for Global Health and Global Surgery will not shift to the Global South without asking hard questions, having uncomfortable discussions, and making considerably decisive efforts.6 14–18 The burden of breaking down the metaphorical chains of colonialism and neocolonialism in the Global South is on ourselves.15 19 The ‘decolonisation of the decolonisation movement’ that others have called for12 involves, among other things, the Global South turning the lens inward and looking at itself. The biggest irony of global health as a discipline is that its success-that is, an equitable playing field for Indigenous people and the Global South- would likely herald a significant dwindling, perhaps even the death, of its demand and practice by the Global North.3 4 This makes the Global South its own biggest stakeholder, as we stand to benefit the most in the process and achievement of decolonisation.

“…until we shift to a place where we do not need Other in order to understand Self, the anchor of coloniality will remain.” – Sylvia Tamale, Decolonization and Afro-feminism20