Global health: the long road from saviorism to justice

Image credit: original artwork from the authors, Evelyn Rogan and Madhukar Pai, free to reuse (CC BY 4.0). Download a higher resolution file via link below..

By guest contributors Evelyn Rogan and Madhukar Pai

We’ve all heard of some version of this story. Imagine you are walking along a river, and you spot a child drowning. You jump in and save the child, as you should. As you celebrate this success, you spot another child further up the river. As you help that child, you spot another. And another.

Your focus on rescuing drowning children prevents you from looking up to see what is causing the children to fall into the river. Children continue falling into the river and there will always be more, because nobody has fixed the reason why they are falling in, or being pushed in.

A quote by Desmond Tutu emphasizes the importance of addressing the upstream causes instead of consequences: “There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they are falling in.”  

In a 1975 paper, John B. McKinlay narrated a similar story and wrote about the metaphor of upstream versus downstream factors. This metaphor has motivated many to think about upstream causes, and ask why systems are letting people down.

For example, Juliet Young, a clinical psychologist, has applied this metaphor to illustrate upstream causes of poor mental health. Young’s work has inspired us to visualize this metaphor within a global health and development context (Figure).

We hope individuals in the global health space will use our artwork to illustrate the difference between band-aid efforts rooted in saviorism and successful initiatives focused on collaboration, justice, and solidarity.

The global health and development sectors have deeply entrenched biases and inequalities originating from its Global North-dominated and colonial roots. Teju Cole refers to these biases as a “white-savior industrial complex.” Power asymmetries result in powerful and privileged individuals and institutions determining the sector’s objectives. Charitable initiatives often follow a saviorism model by addressing downstream outcomes while overlooking root causes. This perpetuates a continual reliance on aid, maintaining power imbalances between aid-providing and aid-reliant countries. Even the language used by these sectors tends to be hierarchical (e.g. donors versus beneficiaries).

The saviorism or charity model of global health is antiquated, unjust, and unfit for purpose, as we saw, firsthand, during the COVID-19 pandemic, where the world failed on vaccine equity. We are now seeing this play out again with the abrupt, violent withdrawal of the United States from multilateralism and the steep cuts in international aid by the US and several other western nations. We have seen that charity can suddenly dry up, and there is no accountability for abruptly cutting off aid. When solutions to hunger, poverty and disease are imagined by the most elite, they are likely to get it wrong.

The global health sector must use the current crisis to expand to scale bottom-up and collaborative solutions that identify and address causal factors upstream of their associated health impacts. These upstream factors include poverty, racism, colonialism, patriarchy, structural violence, and social, political, and environmental determinants of health. Addressing the root causes of health vulnerabilities will require a shift in power, but will support long-term, scalable, and structural change. This will reduce power asymmetries produced by aid-dependency, increasing equity and meaningful representation within the global health sector.

Our artwork shows that upstream causes are complex, interrelated, and challenging to address. However, working to understand these systems and the root causes of health vulnerabilities is required to shift from short-term, band-aid solutions to scalable, system-wide change. Ultimately, the global health and development sectors must pivot from charity towards solidarity, to realize their full potential to achieve lasting structural change.

About the authors:

Evelyn Rogan is a recent BSc Environment graduate from McGill University, Montreal. She is focused on the intersection between environmental/social sustainability, food systems, and One Health. She aspires to continue to leverage her artwork as a communication tool in this space.

Madhukar Pai is a professor of global health at McGill University, Montreal, where he teaches several courses on global health.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.