Decolonising medicines and global health: We need genuine and lasting reforms that put patients in the driving seat
Dr. Tammam Aloudat, Senior Strategic Advisor, MSF Access Campaign
I will admit that good things can, under some circumstances, come out of bad things. A Renaissance can come out of the Dark Ages, human rights out of standing up for tyranny, and humanitarianism out of war. A single death outside a shop in Minneapolis can, as we have seen recently, ignite a flame for change that might yet set in motion global change.
The transition, however, is rarely clean. Too often, traces of the original evil linger on to tarnish the new world that is born.
Tropical medicine falls very clearly into this category. A discipline founded to protect the soldiers of empire from disease and enable their continuing oppression of colonial subjects, it has morphed over the last few decades into a discipline of ‘global health’ which, at least in principle, seeks equal access to quality healthcare for all.
Colonial tropical medicine undoubtably delivered real health benefits. It led, for instance, to the identification both of malaria and its first treatments. These successes, however, will always be tainted by the association with its original purpose.
Today, global health, including the movement to open up access to medicines — our own focus at the Access Campaign — still carries the residue of a racist and colonial past that, while we reject and attempt to rid ourselves of it, remains in many of the details of how the system is built, maintained, and functions.
This discrepancy between those with the power and those without, when it comes to determining global health policy, never ceases to strike me when taking a short stroll around Geneva near our offices. You will pass by the UN, the World Health Organization, Gavi, the Global Fund, UNICEF, and others. You can look through the windows and see the meetings taking place where life-and-death decisions for many millions of people halfway across the world are being made. People in those offices, along with large foundations, government health donors and others in the global health oligarchy, have much power and little accountability.
“You can look through the windows and see the meetings taking place where life-and-death decisions for many millions of people halfway across the world are being made.”
It’s a very curious thought. What happens here defines the life chances of families and communities thousands and thousands of miles away, far from Lake Geneva and its diplomatic luxury cars lining the glittering lakeside.
It has been long known that colonialism has changed its face dramatically in the past decades. Neocolonialism today is not carried out by soldiers with guns and bayonets, it is done by people in sharp suits who have the backgrounds, connections, and resources to decide the fates of others.
Too often, even with the best intentions, health actors can unwittingly be complacent in that colonial behaviour. There is a hair between being a defender of people’s right to health and being a colonial tool that throws them the crumbs so they can be silent as they continue to be exploited.
“There is a hair between being a defender of people’s right to health and being a colonial tool…”
Neocolonialist attitudes in medical and humanitarian organisations can be discerned in many ways: strategic decisions are exclusively made at the top of the hierarchies and in the centres of power, usually by a narrow stratus of people; those making the biggest decisions are much more privileged and much less at risk than those affected by them; “consultations” and “advocacy” take place among a limited and exclusive group of people who are neither diverse nor willing to stray far from the conventions.
It is not a healthy state of affairs.
However, demanding and enacting wholesale change of this system risks harming the very people we serve in MSF and whose lives and health are dependent on the admittedly imperfect way things work now.
On the other hand, pushing for just minor reforms could be even worse. They will do little beyond addressing the symptoms and not the roots of the injustice and will deepen global health’s complicity in the continuing and oppressive status quo. They will not reduce the inequality of decision-making power over who lives and who dies.
I therefore suggest here an alternative approach, a ‘non-reformist’ reform based on a concept first put forward by philosophers and sociologists in the last century in relation to labour movements. This kind of ‘reform’ aims to deliver fundamental change that holds human needs as the optimal purpose rather than the preservation of the system of power.
It is a system of reform that originates from the people who need it and aims to achieve what they need, rather than emanating from a shiny lakeside palace in Europe. And while it doesn’t aim to break the system at all costs, it clearly wants to reshape the system and the power balance to serve the greatest needs of most people.
This is a type of reform we could be proud to enact.
This approach stands starkly against the currently pervasive ‘reformist’ reform, which considers what is possible only within the limits of the status-quo and tries to improve the outcomes through top-down approaches that never challenge the hierarchy of power that causes the harm in the first place.
The MSF Access Campaign works on shaping policies that eliminate the barriers to access to medicines, vaccines, and diagnostics that prevent some of the most vulnerable patients from getting the medical care they require.
Now, COVID-19 has put the issues we tackle everyday right at the centre of the global stage: the availability of new medical tools such as treatments and vaccines, the prices, the monopolies of a few pharmaceutical companies, the competition among rich countries to hoard such resources at the expense of poorer countries, and the lack of global cooperation in favour of narrow nationalistic interests, have all come into the full glare of the spotlight.
None of this is new, it is just supercharged health inequality. However, I am not writing here to discuss that part of the story which will result in medicines and vaccines that become more available for the rich and continue to elude the poor.
No. The issue that troubles me today is that COVID-19 has emphasised, in addition to the economic and nationalistic inequalities, a major power imbalance between those who are trying to tackle the problem. Those most affected have, once more, been bypassed in the rush for solutions. ‘Nothing about us, without us’ is the clarion call of civil society everywhere for meaningful inclusion and participation in developing solutions to issues that primarily affect them. It is more important in this time of COVID-19 than ever before and is once more being ignored.
Which is where we come back to non-reformist reform and the need to put patients and their communities in the driving seat. And if the notion of non-reformist reform strikes you as too radical in the current global health arena — like a person in ripped jeans and a shabby shirt shouting at a black-tie party — we take some comfort in it since MSF has always been exactly that, the shabby person shouting in the polite party and the ones barging through impossible contexts to provide medicine for people few others believe should get it.
However, we in MSF also need to take a long deep look at ourselves. Before we rage against the machine, we must look in the mirror and determine to rid ourselves from our own remnants of a colonial past. We have, to be honest to our aims, to become a decolonised and decolonising idea and organisation that takes its legitimacy from the engagement and power of the people on the receiving end of our services rather than from only those at the top of our hierarchy.
Being a global health practitioner, as an organisation or individual, should be a radical act of rebellion against the system of power.
 Much of the literature on non-reformist reform comes from socialist labour and anti-capitalist movements. A general description of the concept and uses can be found on Wikipedia (https://en.wikipedia.org/wiki/Non-reformist_reform#:~:text=Non%2Dreformist%20reform%2C%20also%20referred,of%20what%20should%20be%20made)
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