Introduction
Global Health as a discipline today (which includes its constituent fields like economics, law, and medicine) is descended from turn-of-the-century developments of what was then called tropical medicine, a field established and cultivated to promote the colonial enterprise.Reference Halabi 1 Since then, the institutions and personnel dedicated to addressing global health remain firmly entrenched in high-income-countries (HICs). Scientists born and raised in HICs receive large investments from their governments to work in well-resourced laboratories, and publish papers in journals controlled by wealthy corporations, monopolizing knowledge production to the near total exclusion of scientists and readers in the countries with firsthand knowledge and expertise. Medical breakthroughs remain frequently based on resources or practices in low-and-middle-income countries (LMICs), with little or no credit or ensuing benefit shared. They are discovered in universities and institutions that benefited from and were established as part of colonial enterprise.
In 2014, Lawrence Gostin published the first edition of Global Health Law in which he compelled his readers — nearly every student, researcher, and policymaker in the field — to confront the structural realities of racism, colonialism, sexism and classism that impeded true “global health justice.” As a result, Global Health Law is far more normative in tone and prescriptive in approach — at times even (justifiably) angry — than his prior work. 2 Where blackletter law and legacy organizations in Western discourse had failed to effectively address these barriers — devastatingly illustrated by the HIV/AIDS pandemic — Gostin’s approach echoed the kind of justice the decolonization movement sought at the heart of the debate.Reference Winnike 3 This essay seeks to briefly map how the history of colonization has shaped global health, and to highlight the scholarly contribution Global Health Law has made to critical discussions on the urgency of decolonizing the field.
Colonialism and Global Health: The Construction of Medical Knowledge for Empire
One of many tools of empire, tropical medicine, which is synonymous with colonial medicine, focused on the European experience with diseases which were viewed as threats to the civil and military administrations constructed to control Indigenous populations.Reference Abimbola and Pai 4 Tropical medicine was, in short, to ensure the health and well-being of conquering European forces in Africa, the Americas and beyond.Reference Kwete 5 The London School of Tropical Medicine and Hygiene, to this day one of the world’s leading global health research institutions, was established in 1899, designed to address the high costs to the British colonial offices from the high mortality rate of officers and white settlers from diseases like malaria.Reference Martin 6 Tropical medicine as a system was further used to uproot indigenous health practices, establish facilities and institutions that fit poorly with local needs, and undertake human experimentation on the local Indigenous populations, who were dehumanized by the colonial practice of racial stratification. 7 Additionally, means of knowledge production through publication and academia were designed to benefit colonization; for example, The Lancet journal supported colonial efforts by publishing reports on military campaigns and research on sustaining health for British troops during wars of territorial conquest.Reference Khan 8
Colonialism and the Early Global Public and Private Institutions
Colonialism pervaded even the earliest global public and private institutions. For example, the International Health Board of the Rockefeller Foundation, the largest health philanthropic organization, founded in 1913Reference Birn and Fee 9 “to promote the well-being of mankind throughout the world,” financed the League of Nations Health Organization (LNHO).Reference Weindling 10 The League of Nations, and by extension, the LNHO, were defined by the strategic interests of various empires, with the League itself being viewed as an “imperial project,” largely focused on serving the interests of European population groups.Reference Akami 11 By 1937, the LNHO had begun regularly producing monthly medical statistical reports covering 72 percent of the world’s population, and focused on metrics and diseases that would affect colonial powers, including forerunners of later versions of health indices. 12
The LNHO treated much of Africa as extensions of colonial powers. Only Liberia, Ethiopia, and segregated South Africa from Africa participated.Reference Tilley 13 Ultimately, the scientific standards and frameworks, and the legal doctrines and institutions, formed the backbone of the current global health governance system. 14 In the same period that the Rockefeller Foundation supported these early global structures, it had spent only three percent of its total grants on African populations by 1951. 15 And while an abundance of funding allowed Europeans access to the latest medical innovations, “In Africa, laboratory facilities were lacking and patients could not be relied on to undergo protracted courses of treatment with drugs that anyway might not be regularly available.” 16 A problem that persists to this day.
From the LNHO to the WHO: The Inherited Colonialism of the World Health Organization
In the words of Audre Lorde, “The Master’s tools can never dismantle the Master’s House.” Reference Hussain 17 In the World Health Organization (WHO), we inherited the same system of global health designed to uphold colonial interests that necessitated the creation of the LNHO. The WHO was formed in a political climate where European countries were struggling to maintain control over colonial empires and territories.Reference Fee, Cueto and Brown 18 In its early days, the WHO was driven by the United States’ resources and priorities, rather than by the needs of current and future member states. As a result, its early governance was shaped by the capitalism-communism rivalry which glossed over the relationship between social, economic, and health problems. 19 This ideology emphasized technical assistance through knowledge transfer to LMICs as the silver bullet to addressing health inequalities, and avoiding addressing underlying social realities — such as colonial oppression — that led to poor health outcomes. WHO’s early leaders and experts were Europeans who had trained in colonial medicine along with its biases.
These biases were reflected at every organizational level. Today, WHO has six regions that correspond roughly to continents, but in its early years, WHO created only five regions excluding Africa, as European colonizers asserted that they could address the health needs of the populations they controlled. Some colonies, led by White governments, were allowed to have certain designations like “associate” members. Thus, in late 1951, almost three years after the creation of the WHO, the first AFRO Committee meeting took place in Geneva and was attended by colonial powers, Belgium, France, Portugal, Spain, the United Kingdom, and also by two African countries, apartheid South Africa, and Liberia — and by a representative of its first associate member, [the former] Rhodesia under White rule at the time (now Zimbabwe). 20
A Changing Governance Landscape
As decolonization swept the globe over the course of the 1950s, 1960s, and 1970s, the increased voice of newly liberated countries shifted the composition and decision-making norms at the WHO and elsewhere. Maternal and child health, investments in immunization, and the eradication of smallpox became priorities and, for those decades, significant strides against diseases that affected populations in LMICs and even efforts at building research and health infrastructure capacity in those countries gained. The 1980s and 1990s brought about a changing landscape for global health governance defined by these shifting priorities, increased global attention to infectious disease, and by the arrival of new public and private actors who would come to fundamentally reshape the field.
Infectious Disease and the Governance Legacy of the AIDS Pandemic
The onset of the HIV/AIDS pandemic marked an important inflection point for the shape of global health governance, as it catalyzed civil society and private entrants into the governance and funding spaces, and elicited meaningful engagement from both HICs and LMICs, even if the former tended to see it in national security terms, while the latter overwhelmingly suffered its toll.Reference Brandt 21 AIDS placed global health on the United Nations agenda, and in 1996, the United Nations officially formed The Joint United Nations Programme on HIV and AIDS.Reference Knight 22
The AIDS pandemic brought to center some of global health governance’s most fundamental equity challenges, as debates over access to medicines took hold at the center of the pandemic.Reference Gostin 23 Within the AIDS pandemic, advocates shone light on global health’s failure to achieve access to medicines for all, and brought to force conversations about how western intellectual property schemes, upheld by the World Trade Organization, perpetuated inequities between the rich and the poor. 24
Private Actors in Global Health
In the late 1990s and early 2000s, resultant and growing tension over inadequate access to medicines and vaccines gave way to the establishment of new public-private partnerships (PPPs) in global health as the WHO looked outward to find innovative solutions to existing problems. The Global Fund to Fight AIDS, Tuberculosis and Malaria (2002) and Gavi, the Vaccine Alliance (1999) brought about a new model in global health which put private funding front and center and created a lasting legacy that some have referred to as “philanthrocapitalism.” As PPPs have taken a long-term hold in the global health landscape, critics of these institutions have pointed out their disproportionate influence over the global health agenda, and lack of public accountability.Reference Brown, Cueto and Fee 25 However, from their inception, they better internalized the division between HICs and LMICs, including more representatives from LMICs in their governance structures, and in some circumstances, emphasizing local needs, ownership, and control of interventions.
NCDs, LMICs, and the Framework Convention on Tobacco Control (FCTC)
While the 1990s gave way to increased international focus on infectious disease, it wasn’t until the 2000s that non-communicable diseases (NCDs) meaningfully garnered the attention of global health’s institutions, and their comparatively large global disease burden.Reference Roemer, Taylor and Lariviere 26 Despite common conceptions that NCDs are primarily a challenge for HICs, 77% of the burden of non-communicable disease is borne by LMICs, and that number is only projected to increase. 27 In 2005, the WHO adopted its first ever Article 19 treaty when the Framework Convention on Tobacco Control entered into force, and has since remained focused on leveraging governance tools to reduce the global burden of NCDs.Reference Roemer 28 Evidence suggests that LMIC’s disproportionate share of the global NCD burden is traceable to the impact of globalization and rapid urbanization on LMICs.Reference Labonté and Ruckert 29
Persistent Colonial Legacies
Inequities in both global disease burdens for infectious and non-communicable disease are evidence of enduring legacies of colonialism in the global health order. Persistent inequities in access to medicines and strongholds on intellectual property regimes that entrench those inequities are demonstrative of the strength of this field’s original power balances. As recently as 2024, real and normative power imbalances between LMICs and HICs fundamentally defined negotiations for a new pandemic treaty, and resulted in roadblocks to reaching truly equitable solutions within the terms of the accord.Reference Campos-Rudinsky 30 Meaningfully decolonizing global health institutions requires revisiting and redesigning the formative structures of global health governance, in order to create new and inclusive pillars that allow for balanced decision-making, priority setting, and accountability for all. 31
Gostin’s Global Health Law and its Impact on the Inherited Colonial Legacy
Global Health Law was in many ways a departure in the trajectory of his scholarly impact. Gostin’s Public Health Law: Power, Duty and Restraint was pathbreaking but ultimately a work of positive assessment. Public health fundamentally relies on a difficult balance between the rights of the individual and the needs of the community, and Public Health Law did more than any previous text to elaborate how that balance could be achieved in light of constitutional, statutory and ethical priorities.Reference Berman 32
Global Health Law was published along with the world’s realization that what started out as a relatively few clusters of Ebola cases in West Africa would become a global emergency.Reference Studdert 33 While Gostin did mention Ebola as one of several emerging infectious diseases that represented some of the failures of then-existing global health institutions, what is more impressive is how well he mapped the lifecycle of an epidemic outbreak, taking into account the strengths and weakness of the WHO and broader global health ecosystem highlighting their past biases as part of the problem. The most damning prophecy from Global Health Law was that a slow response to a health crisis on the part of the HICs hiding behind the guise of cautious policies may effectively amplify the effect outbreaks will have on populations in LMICs. That is precisely what happened with Ebola. The WHO refused for months to acknowledge the threat the growing infections posed; the precious few pre-vaccine medical interventions were given to Europeans and Americans; and when a vaccine finally was developed, it languished in financial and legal uncertainties that really affected only the governments and corporations in the West.
Global Health Law’s structure attended to the embedded colonial norms criticized as part of global health architecture.Reference West-Oram 34 The book starts with, and threads throughout, the stories of those living on the periphery of the full capabilities humans should enjoy by virtue of being human, placing people in LMICs countries at the center of his approach. As he broadly maps global health architecture in Part I, he reviews the global health challenges of the 21st century, highlighting their origin in past geopolitical injustices. Part II introduces the key institutions in the field, from legacy players like the WHO to newer players like the Gates Foundation. For each of these players, Gostin is careful to note their potential impact, but also the responsibility and awareness they must exercise in order to avoid the disparities and injustices like those that prevailed under the LNHO and during the early years of the Rockefeller Foundation. 35 Part III delves into the various sources of law most relevant to global health while analyzing their strengths and weaknesses, using treaties like the FCTC as an illustrative example of the predatory remnants of colonial structures that prevent true equity in global health. Finally, Part IV looks ahead and takes a predictive approach to describe what the challenges facing global health and governance will be, specifically highlighting pandemics, noncommunicable diseases in the global South, and health worker deserts.
Gostin’s plea for urgency was tragically borne out by the Ebola outbreak that same year and half a decade later by COVID-19.Reference Harris and Arden 36 With respect to the latter, Gostin even anticipates COVAX, the international facility set up to procure vaccines for countries that cannot afford them. 37 Gostin’s plea that readers not become complacent in working to improve global health structures in the face of ever more interwoven issues of global politics and what he terms “global health hazards,” such as migration, environmental degradation, drug trafficking, and lack of universal monitoring for transnational corporations in industries like pharmaceuticals or food, all of which are anchored in the colonial era.Reference Dagron and Gostin 38
Conclusion
Decolonization of global health requires not only “reviewing global health through the lens of colonialism or coloniality, in order to interrogate the role of power, injustice and exploitation in the practice of global health,”Reference McCoy 39 but dismantling all manifestations of supremacy within all spaces of global health practice, within countries, between countries, and at the global level.Reference Abimbola and Pai 40 It means that knowledge production must de-center European methodologies, practices and approaches, and institutions, and give due regard to local and Indigenous knowledge. 41 Additionally, “Governing bodies should have diversity in thought, gender, social, geographical and ethnic backgrounds”Reference Khan 42 — the WHO only had its first Director General of African descent, Dr Tedros Ghebreyesus, in 2017, nearly 70 years after its creation.Reference Gostin 43 Modern-day disease outbreaks such as COVID-19 have highlighted the failure of global solidarity to address continued health inequities 44 associated with race and geographical regions, evidenced by the emergence of vaccine apartheid.Reference Sirleaf 45 Gostin’s Global Health Law hews closely to these themes and mandates, acknowledging the layers of global health architecture that emerged near the turn of the century, which have hampered global health justice in our time.
