Editor’s Note (12/21/21): This article is being showcased in a special collection about equity in health care that was made possible by the support of Takeda Pharmaceuticals. The article was published independently and without sponsorship.
COVID-19 continues to wreak havoc across the world, accounting for more than 2.7 million deaths so far; prolonged economic shutdowns; and the dismantlement of global health systems. In no small part, this is due to failures of governance and intentional health policy choices. Despite the swift and unprecedented development of multiple COVID-19 vaccines, more than 66 percent of the countries around the world—predominantly in the Global South—have yet to receive a single vaccine dose. In comparison, 10 countries have received 75 percent of the global vaccine supply. These appalling statistics represent the outcomes of contemporary neocolonial approaches—policies, programs and global governance structures that continue to sustain the same power dynamics and outcomes as during colonization—towards the non-Western world.
The Western world's inability to move past its colonial mentality continues to perpetuate structural violence and social inequities across the globe. COVID-19-related global health inequities, including in vaccine distribution, highlight our global health governance and programs' failures that uphold a Western commitment to the colonial status quo while relegating Black and brown people to collateral damage.
GLOBAL HEALTH’S COLONIALIST ROOTS AND GLOBAL HEALTH DIPLOMACY
Global health is the newest depoliticized and dehistoricized iteration of colonial medicine. Colonial medicine, which was started to protect white people from diseases present among colonized Black and brown people, has also been known over the years as international health, imperial medicine and tropical health. As part of the colonial agenda of “civilizing” the colonized populations, one of the historical aims of global health was to dismantle local systems of knowledge, including health and medicine, and impose Western biomedical models instead. These colonial foundations of global health continue to persist in the United States, a settler-colonial nation. Nevertheless, global health is often taught uncritically, without a deeper reflection on Western scientists' social position as part of the Global North’s scientific enterprise and related positionality; power dynamics; historical context; and contemporary colonial approaches such as top-down global health governance and programming.
Global health diplomacy, a critical tool in the U.S. foreign policy tool kit, is perhaps one of the key mechanisms that perpetuate contemporary colonialism. Rooted in white male saviorism, global health diplomacy often maintains imbalanced power dynamics. Further, it approaches formerly colonized, brutalized and looted nations—colloquially known as “developing countries”—with a deficit model that positions Western society as an omniscient benefactor for the rest of the world. This attitude is reflected in the top-down global health models imposed on countries in the Global South. From the Trump administration's global gag rule to the Obama administration's promotion of LGBTQ rights, U.S. global health assistance too often comes with demands in sociocultural infrastructure changes that reflect the desires of the political party controlling the White House.
To be abundantly clear, women's health; access to sexual and reproductive services; and LGBTQ+ rights are fundamental values that should be a part of the U.S.’s global agenda. However, it is critical to note that the Western morals imposed on the global population during colonization have caused many of the regressive, inhumane policies such as anti-LGBTQ+ laws to begin with. To that end, we must more consciously distinguish between health diplomacy that actually meets the needs of historically disenfranchised global populations and policies that merely advance an imperialist U.S. political agenda.
RETOOLING GLOBAL HEALTH DIPLOMACY
U.S. health diplomacy can be an excellent tool for global social good if approached with a decolonial, anti-imperialist and equity lens. The COVID-19 pandemic has highlighted an increased need for global cooperation to take on challenges such as the existential threat of climate change. Despite this, the U.S. spends only a fraction of its foreign policy budget on financing global health diplomacy; the State Department and the U.S. Agency for International Development combined constitute roughly 1 percent of total spending. Instead, we see that the lion's share of spending goes to prop up a military-industrial complex that, as highlighted by COVID-19, is not what we need to make America safer in the 21st century.
It is important to note that some military spending targets global health as a part of the strategic engagement activities; however, there is no central accounting mechanism for such spending. Global health diplomacy can and should play a central role as we work towards a safer world for both the U.S. and other countries. However, through a process of unlearning and reimagination, global health diplomacy must take an aggressively decolonial approach to ensure it is not reproducing colonial power structures and dehumanizing paradigms rooted in white supremacy.
EQUITABLE GLOBAL COOPERATION: KEY TO SUCCESS
As the U.S. prepares to meaningfully rejoin the global stage after four years of isolationist policies, it is important to recognize that we should no longer presume the exceptionalism that has historically dominated U.S. diplomatic relations. Prior to the November 2020 election, public perception of the U.S. in other countries around the world was at its lowest point in 20 years. Furthermore, in contrast to the botched U.S. COVID-19 response, other countries, particularly those outside of the traditional Western power centers, fared much better. For example, Taiwan’s early initiative to restrict travel, implement testing and provide economic support allowed it to drastically limit cases and avoid lockdowns.
Others, like Liberia, learned from their past experience with epidemics such as Ebola to implement comprehensive control measures. Many of the challenges being encountered in the fight against COVID-19 around the world now are grounded in the U.S. top-down approach to global health, which focuses on solving problems in the short term but fails to address broader systemic issues that cause recurring issues. The U.S. has an opportunity to transcend the mythology of American exceptionalism and enter the global stage with humility to learn from and work with countries as equal partners.
At the same time, we must recognize the role that international organizations have played in combating COVID-19, largely with minimal or nonexistent U.S. support. COVAX, a joint effort that includes the WHO; Gavi, the Vaccines Alliance; and the Coalition for Epidemic Preparedness Innovations (CEPI), has taken the lead on securing vaccine doses for 92 countries that can’t afford to buy vaccines on their own, as well as others who are simply unable to secure doses.
We are encouraged by the Biden administration’s recent financial contribution to this effort; however, the delay in providing vaccine doses to these countries until after vaccination has been completed in the U.S. is disturbing. This nationalist approach taken by the United States and other Western countries, particularly around COVID-19 vaccine hoarding, will inevitably not only cause mass deaths in the Global South but also have worse economic consequences than an equitable distribution approach.
Equitable global vaccine production and distribution that does not dehumanize people in the Global South is critical; the U.S. is well-positioned to mobilize its resources utilizing existing military infrastructure to lead these efforts. Beyond distribution, the U.S. should also lead the effort for a COVID-19 vaccines’ intellectual property rights waiver to increase their production and availability exponentially. Moreover, we acknowledge the policy failures, lack of urgency and drastic steps needed to control the pandemic within U.S. borders.
As the Biden administration works to control the pandemic at home, it must simultaneously look outward to both learn from other countries and convey leadership during a time of continued global uncertainty. The administration should continue to engage a wide variety of stakeholders and implement recommended frameworks for the equitable distribution of COVID-19 vaccines. While we commend the swift commitment to rejoin the WHO, true leadership will require significantly increasing U.S. financial support for its operations to support vaccine distribution efforts.
U.S. DIPLOMACY IN A POST-COVID-19 WORLD
A decolonial approach to global health diplomacy will require a radical paradigm shift in our thinking. This will include dismantling a Eurocentric colonial mindset and learning to lead with humility. It must start with acknowledging that the current systems were historically built to maintain and sustain racist, capitalist and white supremacist structures of power. Hence, they will always, by default, limit our imagination and restrict the bounds of the equitable, decolonial practice of global health diplomacy. A new approach will require sustained financing, equitable cooperation with the Global South, and unconditional support for human rights and global public health systems that do not fluctuate with U.S. election cycles.
Beyond sustained financial support for the WHO, U.S. leaders should also focus on collaborating with local stakeholders to promote local development, rather than sustaining a global health ecosystem that primarily supports Western economies from Eurocentric knowledge production to global health jobs in program development and implementation. Moreover, foreign aid support, especially tied to COVID-19 recovery in the short-term, should be separated from the broader U.S. foreign policy agenda.
For instance, the utilization of existing colonial mechanisms such as sanctions have violently destructive impacts on the most socially vulnerable populations’ health and well-being across the world. Many of our existing foreign policy tools are not only inadequate to meet the 21st-century challenges in global public health but also are rooted in white supremacy. Global health and diplomacy scientists, scholars and practitioners need to take a much deeper look at the status quo, reflect and reimagine our approach for an equitable and peaceful future.
After four years of isolationist policies, other countries have stepped in to fill the global leadership gap left by the United States. Other major world powers such as Russia and China have stepped up to expand their spheres of influence by leveraging global health diplomacy. This is a once-in-a-lifetime opportunity for the United States to start fresh with humility, engage in healthy competition with other nations, earn back its credibility and tackle the increasingly complicated global public health landscape while leaving behind its colonial practices. As the effects of climate change continue to unfold, global health and national security will become increasingly intertwined. Therefore, we must act now to reimagine, develop and implement decolonial global health diplomacy.