The unfolding drama that is 2020 continues to shock, with the global anti-racism protests vying for banner headline space with the ongoing response to COVID-19. At first glance the horrific murder of George Floyd in Minneapolis would appear unrelated to the COVID-19 outbreak. However, its continuing effects emphasise a fissure that has significantly affected the manner in which COVID-19 has been manifest in societies around the world. In the UK, concern for the extent to which COVID-19 has disproportionately affected BAME communities, both within the NHS and in communities across the country, has risen since the outbreak began. This concern led, ultimately, to the publication of the PHE report COVID-19: review of disparities in risks and outcomes. Laudable as far as intent is concerned the report ultimately did little to assuage concerns about the continuing effects of COVID-19 on BAME communities. Troublingly, it’s not as if the origins of these effects haven’t been highlighted previously, most recently by Sir Michael Marmot in Health Equity in England: The Marmot Review 10 years on in which he emphasised the ‘social gradient in mortality’ and of the significance of deprivation on health outcomes. Notwithstanding Sir Michael’s contribution, the PHE report omitted explicit references to structural racism as a cause of the disproportionate effect on these communities, a decision that has called into question the credibility of the report, and prompted questions in Parliament by the Shadow Minister for Equalities about the ‘drivers’ that have led to the disparity in outcomes.
Further afield, long standing concerns about vaccine access have (unsurprisingly) risen to the surface with suggestions that the US and UK, at least, will not consider any vaccine developed by their scientists global public goods. Finally, the perennial tropes of African backwardness and deficiency have been rehearsed, with the African people considered to be little more than handy test subjects (at least for certain members of the French scientific community).The catastrophic effects of Police brutality that served as a catalyst for the global protests that continue, the societal conditions that render members of BAME communities significantly more vulnerable to the COVID-19 virus, and the continued portrayal of an entire continent as backward and as some sort of laboratory at the service of the West, are all exemplars of both structural violence and structural racism.
It would appear that here, in June 2020, we find ourselves at a tipping point. Will these apparently unconnected events lead, separately and perhaps ultimately collectively, to a reckoning with the legacies of western colonialism and the effects of neoliberalism (effects helpfully considered by Dr Williams here recently)? For global health there are signs, particularly through the embryonic decolonizing global health ‘movements’, that at the very least there is a recognition of the need to attend to the structural issues that perpetuate health inequities around the globe. However, I (for one) am concerned that these efforts, at least as currently framed, offer little prospect of meaningful change. By contrast, after the initial successes of the US Civil Rights movement and the intervening decades of atrophy (in terms of the absence of continued improvement in the structural issues that pervade the US) the death of Mr Floyd appears to have had a dramatic catalytic effect, not least with the announcement of the intention of the Minneapolis Police Department to dismantle its Police department.
For those of us in the global health community who are preoccupied with such things this moment is critical. Will the legacies of colonial medicine that continue to blight global health finally be made explicit? Will the chain that leads from colonial medicine to international health and on to global health, within which occurred the US NIH exploitation of the Hagahai community in 1995, the 2007 virus sharing dispute between the west and Indonesia, and the removal of 100s of thousands of blood samples from West Africa in 2014-16 finally be broken? Perhaps most pressing of all, will any COVID-19 vaccine prove to be a global public good or, as appears to be the case with respect to US and UK efforts, will its allocation be initially prioritised for their citizens?
As far as global health is concerned the decolonizing ‘movement’ is yet to effectively articulate an image of, or strategy for, meaningful change that addresses the myriad structural issues that lead to persistently poor health outcomes in the non-West. Perhaps the global health community can draw inspiration from the recent achievements of the BLM movement in the US (particularly), employing COVID-19 as its own catalyst for meaningful change beyond the apparently superficiality of a burgeoning movement that appears to be conflating diversity and inclusivity with decolonization. None of this is going to be easy, I’m told nothing worth having is.
As each new revelation emerges in relation to the structural violence and racism in (or perpetrated by) the West, be it in the context of civil rights or the field of global health, emerges I despair, with every utterance of empty rhetoric I am annoyed, but with every act of defiance I am inspired. I remain frustrated and preoccupied by the recognition that my rejection of the structural violence that we continue to witness is contradicted by my complicity, to date at least, in the same, by the knowledge that I've yet to move beyond rhetoric to action (and that I don't even know what 'action' looks like). Apparently less uncertain is the UK government and its press (read that how you wish) who seem determined to convince us that we are at the beginning of the end as far as the outbreak is concerned, and apparently way beyond that with respect to structural racism. I suggest the reality is we (all of us) are at the end of the beginning, in terms of COVID-19 and in dealing with the legacies of colonialism in global health.