Helping or Hurting? The Duality of Global Health and How to Fix It

By contributing authors Tishina Okegbe, PhD, MPP and Temi Ifafore-Calfee, MPH, PMP

Historically, global health assistance has been delivered largely by high and upper-middle income countries, the so-called Global North. These countries export “technical expertise”, often furnishing financial and human resources to low- and middle-income countries, frequently referred to as the Global South. Annually, OECD and donor countries spent over $150 billion on foreign aid with a subset targeted to advance global health goals and priorities abroad. While we celebrate declining poverty rates, improving maternal and child health outcomes and ending the HIV/AIDS epidemic, deeper investigation leads one to question the purportedly altruistic nature of the Global North. In fact, one may find that an element of duality exists. 

Global health assistance has its origin in colonization, though development agencies, donors, academic institutions, and global health practitioners seldom refer to this history. As a result, health systems across the globe model themselves on systems established by former colonial powers. These systems are held up as the ideal to which the Global South should aspire. The consequences of the Global North not recognizing the enduring imprint of colonization and imperialism results in continued subjugation of the Global South through the provision of global health technical assistance. 

The negative impact of the North-South dynamics is evident. People from the Global South regularly report being ignored, silenced, and excluded from funding decisions that affect them. Several studies have highlighted the extraction of intellectual property from the Global South as reflected by principal authors from outside countries of research, including a recent Lancet Global Health commentary. Global health organization staffing models built on highly paid Global North leadership and inexpensive Global South labor may result in adverse work conditions. Moreover, English and other UN official languages dominate the language of global health fora and publications, further devaluing local languages.

In the Global North countries, academic institutions can play a critical role in shrinking the space between the purported values of global health and incongruent actions. This starts by acknowledging the duality that exists and actively working to improve the health and wellbeing of domestic communities of color. Framing the work through a restorative justice lens, Global North countries must also self-reflect. Given that the United States is the world’s largest global health assistance funder, intentionally rectifying ubiquitous oppressive global health practices may motivate other Global North countries to initiate national-level self-inquiry.  

Because systems of oppression are complex and longstanding, we recognize that there is no sole solution to dismantle them. Hence, we offer two recommendations for US academic and global health institutions and practitioners to implement towards mitigating the problematic duality.

1. Establish a global accountability structure to advance equity

We applaud efforts by institutions like the National Institutes of Health (NIH) and the Lancet to address the organizational structures and systems that perpetuate racial inequity. These efforts advance transparency and contribute towards closing the vast research gap on the study of racism and its impact on health practices. However, we’re concerned that these efforts are performative and commitments will fade once momentum passes. US academic institutions can address this concern by establishing a global accountability structure. This structure would create a safe space through which the Global North acknowledges its oppressive legacy and the subsequent impact on the Global South, and truly listens and learns from the Global South. This structure could be coordinated by a body such as the Consortium of Universities for Global Health, whose current membership represents government, US and international institutions, and think tanks. This would lead to a gradual shift in power dynamics, which currently favors the Global North. It will also be important for Global North institutions to hold each other accountable so that the onus does not rest on the Global South. 

2. Champion increased US domestic investment in health for communities of color

US academic institutions also have a role to play in advancing equitable access to quality health services. While domestic communities of color appear strikingly similar to populations the US serves abroad through global health assistance, strategic domestic health investments in communities of colors have been lacking. US academic institutions should employ the same evidence-based decision-making processes domestically that are utilized internationally to determine where resources and healthcare investments should be deployed. By determining the magnitude and geography of the problem, these institutions can assist the government in providing technical assistance to communities in need. 

We acknowledge that these recommendations will not eradicate this duality, as more robust, systemic approaches are needed to shift dynamics that have been in place for centuries. However, they can serve as first steps and can be implemented immediately. We are also inspired by recent US commitments toward advancing racial equity and can envision a decolonized global health field on the horizon.

Tishina Okegbe, PhD, MPP is a global health specialist with 10+ years of experience. She earned her PhD at the University of Pennsylvania and a master’s degree from Princeton University, and is a Term Member on the Council on Foreign Relations. https://www.linkedin.com/in/tishina-okegbe/

Temi Ifafore-Calfee, MPH, PMP, is the acting Managing Director within USAID’s Private Sector Engagement Hub. Her career spans 15 years, holding senior and director-level roles and she is a first-generation American.

Disclaimer: The findings and views in this commentary are those of the authors and do not necessarily represent the views of the United States Agency for International Development or the United States Government.