International Public Health: Revival of the Colonialist Agenda

Colonial regimes are good employers if you are from the colonizing side. They pay well and offer exciting travel to exotic locations. They support your family with benefits and subsidies. And they convince you (because you want to be convinced) that you are benefiting the many whilst, as Rudyard Kipling insisted, carrying their burden. Rather than being an enabler of greed and pillaging, you are really bringing forth civilization, such as with education or healthcare – sacrificing yourself for the greater good. A humanitarian, even if at the beck and call of rich and powerful people.

International Public Health and Decolonization

The World Health Organization (WHO) arose in the aftermath of World War Two, as much of the world was throwing off the yoke of colonial masters. Colonialist approaches varied, from those who built infrastructure and were seen to provide something for those they ruled, to those whose only interest seems to have been loot. Some had conquered well-functioning States, others replaced regimes as brutal as themselves. However, like slavery, colonialism, or imposing one’s will on others for one’s own benefit, is always wrong. Both probably go back as long as humankind, have been ubiquitous across most of history, and remain prevalent today. We have learned to veil them.

The 1950s to 1970s saw half the world move from serving other nations to become more-or-less politically self-governing. It was far from smooth, with European powers ‘freeing’ their colonies based on arbitrary colonial borders and so leaving behind intrinsically unstable States (the Balkans tell us this is not just an Asian or African problem). Another legacy is the ownership of companies that extract resources, with former masters and their allies sometimes going to considerable lengths to maintain this. They ensured that their colonies remained, economically at least, colonies. Companies exist to extract and accumulate wealth, and the rich world wanted their companies to continue gaining higher returns from lower costs after their colonies were lost. Poorer countries tend to have lower costs and less oversight, and with a sufficiently amoral approach, they can be kept that way. Wealth can still flow upwards to the former colonial power, even when the colony is officially free.

The WHO in its early days was relevant to this process as it stood for the benefit of all, its constitution requiring it be controlled equally by each Member State. Each emerging State had one vote in its governing World Health Assembly – equals of their former colonial rulers. This differs from the United Nations Organization (UN) itself, where past colonialists on the Security Council retain a power of veto. Though a UN agency, it was decided that the WHO should better reflect a decolonizing world.

For some decades, the WHO generally succeeded. Many people like to highlight the caveats – “but this Director-General once said this” or “another senior officer said that” – but the organization was bigger than those few. The WHO concentrated on major addressable disease burdens such as malaria, tuberculosis, and later, HIV/AIDS. It helped make others like yaws and leprosy become rare. It prioritized the drivers of infant and child mortality. It also led the smallpox elimination campaign – at least accelerating its elimination. 

Recognizing the main determinants of longer life – improved living conditions, nutrition, and sanitation – the WHO prioritized these and emphasized the importance of community structures and primary care to achieve them. The Alma Ata Declaration of the late 1970s, a million miles removed from the Covid-19 response of 2020, recognized the importance of local structures to health outcomes, reflecting the reality that improving human capital builds longer lives more reliably than chemicals supported by financial capital. As the WHO had no one pushing it to overinflate the risk of profitable diseases, few people actually heard much about it.

Large disease burdens drain economies and prevent communities and countries from getting on their feet, especially when their children and young adults are dying. The inability to address the underlying causes of ill health ensures poverty and aid dependence. Building individual resilience and national capacity should do the opposite, and that was once the WHO’s role. Success in this context would be steadily reducing dependency, with reduced requirements for foreign finance and workers. This, up to perhaps the year 2000, was a common understanding within the international public health workforce. There was supposed to be an endgame to most of this work, where countries support themselves.

International Public Health and Recolonization

Working with the WHO towards the endgame of healthcare self-reliance (or completing decolonization) were relatively few organizations. UNICEF (concentrated on child health), a few foundations like the Wellcome Trust, and traditional schools of tropical health and hygiene. Small non-government organizations (NGOs) worked around these. All, even the Wellcome Trust founded by a Pharma magnate, shared an emphasis on capacity building and on high-burden diseases. Manufactured commodities such as drugs were part of achieving outcomes, but not the primary focus. Western people would study at Mahidol University in Thailand rather than a public health school in America because public health was about communities rather than funders.

The change since then has been dramatic. The WHO and its major pre-2000 partners are now outnumbered in an increasingly lucrative industry. The Global Fund is the main multilateral grant agency for malaria, tuberculosis, and HIV/AIDS. UNITAID, a public-private partnership (PPP), is dedicated to establishing markets for vaccines, drugs, and diagnostics in low-income countries. Gavi, the vaccine alliance, is a PPP buying and distributing vaccines. CEPI, a PPP founded quite extraordinarily at the World Economic Forum meeting in Davos in 2017 almost 100 years after the last major pandemic, is dedicated solely to vaccines for pandemics.

The Gates Foundation, a private charity with strong Pharma alliances, grew to fund and have governing influence over all the above, while the ever-growing World Bank’s health arm houses, among other things, the Pandemic Fund. All these entities share a common interest in expanding markets for commodities or in financing their use. None has the main historical determinants of longer life – improved sanitation, nutrition, and living space – as a primary focus. Their work is not devoid of benefits, but the overall emphasis is clear.

Whole new campuses have been built in Switzerland and the United States over the past 15 years to house the thousands administering this profitable approach to managing health in low-income countries. They were not built in Nairobi or Delhi, but Geneva and Seattle. A thriving industry of non-government organizations (NGOs) serves them, headquartered also in high-income countries. These are staffed by recruits who studied ‘global health’ in colleges sponsored by donors whom they now aim to spend the rest of their lives serving. If there is money to be made manufacturing and distributing injectable chemicals, then they will find public health reasons to do it. If their sponsors prioritize climate, then climate will be a threat to health. If pandemics, then we will be told of an existential threat from disease outbreaks. It is the message, rather than truth, that keeps you employed.

Sponsoring global health schools in rich countries builds the dependent workforce required to ensure compliance with a colonialist, top-down agenda that is actually the antithesis of good public health. A few million dollars to the University of Zambia will likely do far more to address the root causes of poverty and child mortality than tens of millions to the University of Washington, but the outcomes are less well-controlled. Wealthy people have a right to put their money where they want, but the job of agencies such as the WHO is supposed to be to ensure this does not affect policy. They are supposed to ensure that populations, communities, and individuals facing large disease burdens still control the agenda. In this, they have abjectly failed. 

A lot of money buys a lot of consensus. One Geneva salary may support over twenty health workers in central Africa, but the focus of that Geneva-based worker is their own child’s education, healthcare, and holidays. For this, they must keep their job. With a quarter of the WHO’s budget arising from private sources that also specify how the money is spent, the funder’s wishes naturally become the staff’s priority.

These are simple realities. The WHO and other international health agencies do what they are paid to do. Hence, a large proportion of global health staff in Geneva now prioritizes natural pandemic risk, which in the past century has barely impacted overall mortality, over the millions who die as a result of simple micronutrient deficiencies. Whilst flying business class, they support policies that restrict access to fossil fuels in Africa, further embedding the poverty and undernutrition that they know shortens lives. This requires no conspiracy; it is the expected outcome of greed and normal human self-interest.

Facing the Betrayal

These recent changes in global health are not entirely novel. The industry is returning to where it began – in the latter half of the 19^th century with the sanitary conventions that sought to protect the European colonial powers from an influx of plagues arising from their newly acquired assets. A rapid increase in travel was seen to promote recurrent rounds of typhus, cholera, and smallpox. Yellow fever outbreaks hit cities in the United States. Agreements between powerful countries sought to control the movement of people and dictate their healthcare whilst continuing to appropriate wealth. 

We have simply turned full circle. Manufactured narratives such as that on pandemic risk do not just protect the colonial investment but have become a lucrative instrument of the colonial endeavor. The Western-based institutions listed earlier – WHO, Gavi, CEPI, UNITAID – are all developing a global marketplace for mostly Western corporations. Their workforce has become the enablers and enslavers – pulling a veil of altruism over the face of corporate greed to save us from the next ‘public health emergency.’ Funneling wealth from low-income countries prevents the transformation in health that growing economies would bring, maintaining the inequality necessary for the colonial model to work. In parallel with the expansion in the global health industry, the OECD notes that the gap between high and low-income countries has increased by 1.1% annually since 2015.

If international health institutions were succeeding in their claimed objective, of building capacity and improving health, they would be downsizing. In contrast, they are growing while basic interventions such as nutrition are losing funding. The Covid-19 response demonstrated their purpose. While countries across Africa increased debt and poverty, sponsors of the global health industry landed unprecedented gains in wealth.

The buyout of the original WHO dream occurred with the full consent of the workforce. Like the East India companies of a former era, the WHO and its growing partners offer exciting and lucrative careers. Dismantling this will be a painful process for the many thousands on this gravy train, and they will fight as workers would in any large extractive industry under threat.

When the WHO is headquartered in Nairobi or Delhi, we will know public health is once again about populations rather than profit. When the big public-private partnerships concentrate on individual resilience rather than quick fixes tied to patents, we can believe decolonization is the intent. Until then, the global health industry should be treated no differently than any growing industry that uses public money for the benefit of investors. The arms industry is an obvious parallel; they can both extract lives as well as wealth, and they both exploit the old colonial hierarchies.

Seeing public health institutions as the neocolonialist instruments they have become, and understanding what drives those within them, is essential for progress. A future world that is healthier and more equitable is still possible, but the public health momentum is clearly pointed elsewhere.