A Time for Optimism? Decolonizing the Determinants of Health

Jonathan Cohen

The global movement against anti-Black racism has coincided with a pandemic that has revealed and magnified racial inequality, creating a watershed moment for public health.

We are witnessing not only the social, economic, and political determinants of vulnerability to infectious disease, but also the racial and colonial hierarchies that lie underneath these roots. Meeting this moment requires that we look back at the history of public health and ask when our field has acted as a force for racial justice—and more painfully, when it has not.

It has long been clear that the darkest chapters in the history of public health are those in which it has been pressed in the service of white supremacy, colonialism, racial superiority, and ethno-nationalism. From the Nazi medics, the Apartheid health system, and the Tuskegee experiment, to the eugenics movement, psychiatric confinement, and the war on drugs—these have been possible, with public health’s complicity, because race is unparalleled in its power to justify hierarchies of power and privilege.

Yet it is also true that some of the brightest moments in public health history are when the field has acted as a force against racism and colonialism. The global movement for HIV treatment found a crucible in the struggle for democracy in South Africa and the post-apartheid promise of equal constitutional rights. The Alma-Ata Declaration on Primary Health Care sought to rectify global inequality in access to health care. The movement for harm reduction in Eastern Europe sought to throw off the imperial yoke of Soviet “narcology” and embrace values of scientific evidence, freedom, and dignity.

The question we face today is whether a similar breakthrough is afoot—whether changes in policy, practice, and culture that seemed unthinkable before COVID-19, but which now appear within our grasp, will transform the social determinants of health in ways that promote genuine racial equity and global justice.

Signs of change are appearing locally, nationally, and globally. Neighborhoods long marginalized by environmental racism, colonialism, and racial segregation are demanding greater access to public infrastructure, and drawing linkages between their vulnerability to COVID-19, or their exposure to extreme weather events. From inner cities in the United States, to favelas in Brazil, to peri-urban areas of African cities, to indigenous and occupied lands from Latin America to the Middle East, communities are forming multi-issue coalitions to demand access to the social determinants of health for the literal right to breathe. Tired of being uncounted and left off the map, citizens are demanding inclusion in climate resiliency plans, curbs on gentrification, and an end to militarized police raids—particularly in informal settlements where overcrowding and substandard living conditions increase climate and COVID-19 vulnerability.

Similar shifts in power can be detected at the supra-national level. Countries formerly colonized by and dependent on imperial powers are proudly pursuing locally designed and locally financed universal health care schemes, spurred by local activism. Rich countries are under pressure to embrace new models of development cooperation that strengthen the social contract between citizen and state in low-income countries. International financial institutions are moving towards increased financing for building vaccine and diagnostic manufacturing facilities in the Global South to enable the creation of decentralized manufacturing facilities and local solutions to local problems.

The private sector is not immune from these shifts. The new extractive industries are not those who mine gold and diamonds, but rather those who mine data from human bodies—Black and Brown bodies, African bodies, and poor bodies.

Big Tech is quickly occupying a similar space as Big Pharma in extracting value for financial gain, profiteering off public goods in the midst of a racialized pandemic. But communities whose health and rights are affected are pushing back. They are demanding a greater say in the design and governance of pharmaceutical and digital health technology, developing their own solutions using principles of design justice, and centering local and indigenous knowledge systems in fields from mental health to sexual and reproductive health. A new generation of commercial enterprises is responding to the needs of local health systems rather than those of paying customers, developing health technologies that seek to anticipate and prevent pandemics rather than profit from crisis.

Even the multilateral system is recognizing its role in “decolonizing” global health. In his annual lecture at the Nelson Mandela Foundation in July 2020, UN Secretary General Antonio Guterres noted that COVID-19 had exposed “the delusion that we live in a post-racist world” and that “the legacy of colonialism still reverberates” in institutional racism, the global trade system, and global power relations.” Guterres called for a “New Social Contract” and “Global New Deal” that would fundamentally redistribute power, wealth, and opportunity. Days later, the recently appointed UN Special Rapporteur on the Right to Health, Dr. Tlaleng Mofokeng, committed to using her mandate to decolonize global health, including by naming systems of racial oppression that fuel disparate health outcomes, championing indigenous knowledge systems, and promoting an equal voice for local expertise in setting the global health and development agenda.

These remarkable developments share a heritage and a goal. They build on the best traditions of public health to mobilize antiracist and decolonial frameworks against the unequal distribution of power. In so doing, they seek to liberate us from the pandemic of racism itself.

They strengthen the human rights paradigm with a transformational theory of the social determinants of health. While it remains paramount to guarantee a full range of civil, political, economic, and social rights to secure health, it may also be insufficient without the framework and practice of antiracism and decolonization.

Calls for rights-based approaches to health and development ring hollow coming from colonial masters disguised as “development partners.” A vibrant new set of actors—from the Kampala Initiative to rethink aid, to the movement to Decolonize Global Health led by early career global health professionals, to the recently launched Race and Health Movement—needs to be supported to advocate for structural transformation in health, calling for decentering power in global relations, and deploying concepts of racial equity, economic justice, and systems transformation. These actors remain driven by a commitment to human rights, while searching for newer and bolder paradigms.

The twin threats of COVID-19 and anti-Black racism have accelerated this search. The health disparities revealed by COVID-19 are traceable to a deeper set of often racialized and colonial dynamics that are not amenable to traditional human rights action. They relate to what Isabel Wilkerson has called “the muscle memory of relative rank”: a broad understanding of “caste” that “affixes people to certain roles based upon what they look like and what they historically have been assigned to.”

While we have long understood the social determinants of health to include a healthy environment, food security, water and sanitation, we have been slow to acknowledge, much less repair, the racial hierarchies that structure access to these public goods. These are the determinants of health that we prefer not to see. They have not simply been revealed by COVID-19; rather, they have been unearthed and exhumed from the places we chose to bury them. Intervening at these depths may require that we amplify human rights advocacy with antiracist organizing for a new world order.

Success in decolonizing the determinants of health is far from assured. Just as movements to end racism are gaining momentum, so too are efforts to capitalize on COVID-19 for power and profit. As soon as a movement for the “People’s Vaccine” began, vaccine researchers initiated lucrative licensing deals with multi-national pharmaceutical companies. Weeks after COVID-19 portended a decline in the prison population, Human Rights Watch reported that known releases amounted to only 5% of the global prison population. What Arundhati Roy eloquently called a “gateway between one world and the next” seems only to be as much of a gateway as we make it.

But power mutates, and the greatest transformations in public health have occurred when different forms of power come together in common cause. The movement for HIV treatment succeeded when grassroots activists joined with elite scientists to change the way we think about medicines, from a commodity to a human right. Similar transformations are possible today.

What is at stake is a new world order in which people in their full diversity, complexity, and humanity share power over the decisions, resources, and stories that shape their physical and mental health and well-being.

This vision, carved by the tragedy of COVID-19 and in the racial inequities it exposes, provides a stark moral contrast to the authoritarian use of “othering” to create hierarchies of benefit and consolidate political power. It calls attention to the full range of power differentials between people, groups, and countries that perpetuate health disparities. It addresses the inequalities that have been baked into our current global economic order since the colonial era. It transcends the language of human rights to encompass racial, economic, and gender justice and—crucially—the way they intersect to shape human diversity and complexity. For public health, it furthers a move away from the biomedical and behavioral prevention and treatment of disease, to the equitable sharing of power between people, communities, and societies.


The author wishes to thank the staff of the Public Health Program for encouraging and influencing these ideas.

Jonathan Cohen is Director of the Public Health Program, Open Society Foundations, USA. Email: jonathan.cohen@opensocietyfoundations.org