Decolonizing Global Health Means Rethinking Its Core Goals

The Question Nobody in Global Health Wants to Answer

In July 2021, a group of global health experts gathered in Wuhan, China, for a symposium that was supposed to be about decolonizing their field. They knew the usual critiques: that Western institutions still call the shots, that funding flows from rich countries to poor ones with strings attached, that local researchers are often treated as data collectors rather than intellectual partners. They had heard all of this before.

But then the conversation took a turn. Someone asked a question that made the room go quiet: What if the entire premise of global health investment is backward? What if pouring money into health programs in low income countries does not actually drive socioeconomic development, but the opposite is true? What if development has to come first, and health gains follow?

The experts could not agree on an answer. And that disagreement, as Xiaoxiao Jiang Kwete and her colleagues later wrote in Global Health Research and Policy, revealed something uncomfortable about the decolonization movement itself (Kwete et al., 2022). The movement wants to dismantle colonial structures. But it has not yet decided what it wants to build in their place.

What Colonial Vestiges Actually Look Like in 2022

Kwete and her coauthors identified three levels of colonial residue still operating in global health. The first is the most visible: institutions. The World Health Organization, the Gates Foundation, the World Bank, and major universities in the United States and Europe still control the vast majority of global health funding, agenda setting, and knowledge production. A researcher in Kenya who wants to study a local health problem often needs approval, funding, and coauthor credit from a partner in London or Boston. The infrastructure of the field remains a one way street.

The second level is harder to see but more pervasive: epistemology. The authors argue that global health has been built on a Western scientific framework that treats biomedical knowledge as universal and local knowledge as anecdotal. When a community in rural Uganda has a traditional understanding of disease transmission that does not match the textbook model, that understanding is dismissed. The textbooks themselves were written in Baltimore and Oxford. The metrics for success were designed in Geneva. The very definition of what counts as evidence comes from a narrow set of academic traditions that exclude most of the world's people.

The third level is the most insidious: ideology. Global health interventions are often packaged with implicit assumptions about progress, development, and modernity. A vaccination campaign in sub-Saharan Africa does not just deliver vaccines. It also carries the message that Western medicine is superior, that traditional healers are obsolete, that the future looks like the present in Stockholm or Seattle. This is not a conspiracy. It is the water that global health swims in. And it is hard to decolonize water.

The Core Assumption Nobody Tests

The symposium participants agreed on something striking. They concluded that the current status quo of global health is still replete with various forms of colonial vestiges, both ideological and practical (Kwete et al., 2022). But they also realized that fixing these problems requires going deeper than redistributing funding or changing authorship practices.

The fundamental assumption of global health, as the authors frame it, is this: investing in health leads to economic development. Healthier populations are more productive. Children who survive infectious diseases grow up to earn higher incomes. Workers who are not sick build stronger economies. This logic has driven billions of dollars in aid and countless policy decisions.

But what if the relationship runs the other direction? What if economic development is the prerequisite for health improvements, and not the other way around? The historical record offers some support for this view. The dramatic health gains in Western Europe and North America during the 19th and 20th centuries occurred alongside industrialization, rising incomes, better sanitation, and improved nutrition. Medical interventions played a role, but they were not the primary driver. People got healthier because their societies got richer, not because doctors cured their diseases.

If this is true, then the entire architecture of global health is built on a shaky foundation. You cannot simply transplant health programs into poor countries and expect them to generate prosperity. You might need to pursue development first, and let health follow. But that conclusion is uncomfortable for a field whose existence depends on the belief that health interventions are a cause of development, not just a consequence.

How the Symposium Worked

The symposium was organized by the editorial board of Global Health Research and Policy and convened over multiple sessions in July 2021. The participants included scholars, practitioners, and policymakers from several countries. They discussed what decolonizing global health means, how to do it, and what criteria to use in measuring whether it has been achieved (Kwete et al., 2022).

The authors do not provide a participant count or a detailed breakdown of who attended. What they do provide is a record of the consensus that emerged. The group agreed that colonial vestiges exist at all three levels. They also agreed that systemic reforms are necessary, not just cosmetic changes. But they did not agree on what those reforms should look like, or how to know when the work is done.

This is not a weakness of the paper. It is an honest reflection of where the field stands. The decolonization movement has been very good at diagnosing problems. It has been less good at prescribing solutions. And the hardest problem of all is the one that the symposium participants identified but did not resolve: the core assumption about health and development.

The Missing Piece: Who Gets to Define Success?

One of the most provocative implications of the paper is that decolonization cannot be complete until the goals of global health are redefined from the ground up. Currently, success is measured in metrics like mortality rates, disease prevalence, and disability adjusted life years. These are useful numbers. But they were created by specific people in specific places for specific purposes. They reflect a particular view of what a healthy life looks like.

A community that values spiritual wellbeing, social cohesion, or connection to the land might have a very different definition of health. A society that prioritizes collective welfare over individual survival might make different tradeoffs. The current metrics do not capture these differences. They impose a single standard and call it universal.

Kwete and her coauthors do not propose an alternative set of metrics. But they do suggest a guiding principle for thinking about solutions: any reform must be grounded in the perspectives and priorities of the people who are supposed to benefit from global health interventions, not the institutions that fund them. This sounds obvious. In practice, it is radical.

What the Paper Does Not Prove

The authors are careful not to overclaim. They do not present new data or test a hypothesis. The paper is a synthesis of discussion, not an empirical study. It reflects the views of a specific group of experts who met at a specific time and place. Other groups of experts might have reached different conclusions.

The paper also does not resolve the central tension it identifies. The relationship between health and development is complex and bidirectional. There is evidence that health investments can boost economic growth, especially in the case of infectious disease control and child survival. There is also evidence that economic growth drives health improvements. The truth is probably somewhere in between. But the decolonization movement has not yet figured out how to navigate this ambiguity.

The most important limitation is this: the paper describes a problem but does not provide a roadmap. It identifies three levels of colonial vestiges and one guiding principle. It does not specify what systemic reforms should look like, how to implement them, or how to measure progress. This is not a failure of the paper. It is a reflection of how early the field is in this conversation. The decolonization movement is still asking the right questions. It has not yet found the answers.

Why This Matters Right Now

The decolonization movement in global health has gained significant momentum in recent years. Conferences are held. Papers are published. Funding agencies issue statements about equity and inclusion. But if the movement only addresses the surface level problems, it will fail. Giving more money to local researchers is good. Sharing authorship credit is good. Diversifying editorial boards is good. None of these changes, by themselves, will decolonize global health.

The deeper work requires rethinking the fundamental goals of the enterprise. If global health continues to measure success using metrics designed by Western institutions, it will continue to reproduce colonial patterns even with the best intentions. If it continues to assume that health investment drives development, it will continue to prioritize interventions that may not align with what communities actually need.

The symposium participants reached a consensus that systemic reforms must be taken that target the fundamental assumptions of global health (Kwete et al., 2022). This is a serious claim. It means that the movement cannot stop at representation and redistribution. It has to go after the core logic of the field itself.

What This Actually Means

The paper from Kwete and her colleagues changes how we should think about decolonization. It is not a checklist. It is not a funding reform. It is a fundamental reexamination of what global health is trying to achieve and who gets to decide.

Here is what this means in practice:

• ▸Any serious decolonization effort must begin by questioning the assumption that health investment automatically leads to development. This is not an argument against health programs. It is an argument for thinking more carefully about context, sequencing, and local priorities. A vaccination campaign in a community that lacks clean water and basic nutrition may not produce the expected economic returns. The solution is not to abandon vaccination. It is to integrate health programs with broader development strategies that address the root causes of poor health.

• ▸The metrics used to evaluate global health programs must be expanded to include locally defined measures of wellbeing. This is hard work. It requires listening to communities, understanding their values, and designing evaluation frameworks that reflect those values. It also requires accepting that different communities may have different definitions of success. A global health program that works in one place may not work in another, and not because the science is wrong. Because the goals are different.

• ▸The three levels of colonial vestiges, institutional, epistemological, and ideological, must be addressed simultaneously. Fixing institutional power imbalances without challenging the underlying epistemology will leave the field with a more diverse set of leaders who still think the same way. Challenging epistemology without addressing ideology will produce new knowledge that still carries old assumptions. All three levels are connected. All three must change.

• ▸The guiding principle that reforms should be grounded in local perspectives is not a platitude. It is a practical constraint that forces difficult tradeoffs. If a community decides that a particular health intervention is not a priority, the field must respect that decision even if it conflicts with global health goals. This is uncomfortable for a field that has long operated with a sense of moral urgency. But decolonization requires giving up control, not just sharing it.

• ▸The most honest conclusion from the symposium is that the decolonization movement does not yet know what success looks like. The authors raise the question of what criteria to apply in measuring its completion, and they do not provide a definitive answer (Kwete et al., 2022). This is not a weakness. It is an invitation. The field needs more discussion, more experimentation, and more humility. The goal is not to find a single answer. It is to build a process that allows different answers to emerge from different places.

The decolonization of global health will not be achieved by a single paper, a single symposium, or a single reform. It will be achieved by a sustained, uncomfortable, and honest conversation about what the field is for and who it serves. The paper from Kwete and her colleagues is a contribution to that conversation. It does not have all the answers. But it asks the right questions. And that is where real change begins.