Introduction
Global public health owes much of its development to the imperial powers’ desire to increase the productivity of their colonies by addressing the diseases which hampered their ability to exploit the land, labour and resources of the global South. Among the first international health programmes were the Rockefeller Foundation’s interventions to treat hookworm, first in the southern United States, and then in Latin America and Asia. These programmes had two central aims. First, to increase the productivity of countries in these regions, and second, to create and promote U.S. influence. This focus meant that there were major disparities in access to healthcare between the European settlers, and the native populations of the colonies.
Fundamentally, because independence did not change the structural integration of the former colonies into the world system, and that the conditions driving disease and under-development in these countries remained in place. Global public health retains and perpetuates the colonial legacy of uneven access to care through its focus on technical approaches to addressing health problems that leave the structural causes of these problems intact. This “managerial” understanding of health problems, based on the reasoning that if scarce resources could be used effectively and efficiently, health problems could be solved, abstracts health problems from the political-economic contexts in which they develop, and reduces them to technical problems with technical solutions. It is an approach that never questions why resources are scarce, but takes scarcity as an unalterable feature of global public health. Richardson, in his exploration of the global response to the Ebola epidemics in West and Central Africa between 2013 – 2019, similarly discusses how future global health professionals are “socialised for scarcity”, and the assumption that scarcity is a reality to be accepted, rather than a political choice to be challenged, fundamentally limits the capacity of countries and global institutions to address the health problems they face.
This technically focused approach to global public health creates deep vulnerabilities in low and middle income countries that are dependent on foreign aid to support their health systems. These vulnerabilities were highlighted in the response to the COVID-19 pandemic. Büyüm et al., for example, discuss the disproportionate impact of COVID-19 on the world’s marginalised populations, and link this to the fact that the global health system is poorly equipped to address structural violence as a determinant of health. They argue that a paradigm shift in global health is necessary to repoliticise global health, and to ground it in a health justice framework that acknowledges how colonialism, racism, sexism, and capitalism pose the greatest threats to health equity globally.
Realising the human right to health
Realising the human right to health requires moving beyond technically focused interventions to recognising that global health inequities are deeply rooted in the political-economic context of the world system. At a fundamental level this shift requires the understanding that resource scarcity within the global system is a political choice that is structured by legacies of colonialism and imperialism. Addressing this scarcity, and realising the right to health for all people, will require the structural transformation of the global economy. As Hickel and Sullivan show, ending poverty and ensuring decent living standards for all, including a full range of necessary goods and services (including healthcare) can be provided for a projected population of 8.5 billion people in 2050 with approximately 30% of existing global productive capacity.
The uneven distribution of death and disease is an inevitable effect of the existing structure of the global health system and the reliance on foreign aid to support global health has created a situation in which the countries of the global North can enact murder on the scale of 350 000 extra deaths per year through cuts to their aid budgets. The callous disregard for the impacts of such decisions among the leaders of these countries highlights the urgency of transforming the global health system to realise the right to health for all people.
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