In the spirit of our founder (the mysterious COVID-19 Diaries), let’s kick off with a little controversy… global health actually just equals colonial medicine. Given the focus of my research perhaps this is not that controversial, but don’t take my word for it. No less than the Royal Society for Tropical Medicine has apparently been ‘dedicated to global health since 1907’, which is pretty nifty given the concept only emerged in the late 1990s. Maybe it’s a sort of half-hearted, subliminal confessional, or perhaps an inside joke? Perhaps this an unwitting recognition that global health is merely a rebranding of international health, itself a previous rebranding of the less than palatable colonial medicine? Beyond the jarring and somewhat naked rebranding of an institution forged in empire, the ongoing COVID-19 outbreak brings the connection between colonial medicine and global health into sharp relief. Moreover, as I shall suggest, it also has had the effect of bringing colonial medicine ‘home’.

Back in 1907 the objectives of colonial medicine (or global health for readers from the RSTMH) were clear; founded in racism the central function was to serve the expansion demands and economic priorities of imperial interests, with any health benefits accrued locally occurring largely when they served the colonial projects’ need for a ready supply of healthy labour. So, what does this ‘ancient history’ have to do with the continuing global pandemic? 

This contribution was inspired by a reminder of the famous Niemöller quotation, ‘first they came for the socialists…’. During the imperial era the devastating effects of colonialism were experienced locally, with the benefits being accrued back ‘home’, benefits that served as the foundation of the societies within which many of us live and prosper. Notwithstanding notable anti-empire advocates there was little dissent, indeed pride in empire is still notable and consistent despite the many decades since its demise. However, COVID-19 has shaken things up somewhat. While the usual pathologizing and ‘othering’ of the so calledundeveloped countries and peoples continues unabated the spatial parameters of this outbreak are different. The populations of the global North can’t observe this outbreak from afar, fascinated by the macabre and visceral reports of brown bodies bleeding from every orifice. Today all of our lives are affected, tens of thousands of our friends and family members are dying ‘at home’ and around us, and this outbreak not characterised by the moral and media fatigue that tends to follow initial reporting of previous outbreaks ‘over there’.

But it’s more than the spatial dimension that is of note this time around. The identities of the surplus populations, those considered ‘less’ have also changed, or more accurately have grown. As the PHE report, ‘Beyond the Data: Understanding the Impact of COVID-19 on BAME Communities’ has shown recently, the risk of death for members of BAME communities was ‘between 10 and 50% higher’ than for White British. But COVID-19 doesn’t stop there. Manual workers, lower paid workers, refuse collectors and the myriad ‘essential workers’ are also experiencing COVID-19 in demonstrably different and far more dangerous ways compared to the middle classes and those making the decisions. Decisions that effectively force those in lowly paid professions to work (either by lack of wage subsidy, declarations of who is and who is not essential, or by structural imperatives that force daily wage earners and those in the informal economy to keep working). This not only threatens their health but also that of their families. Millions living already precarious lives have been plunged into hunger, fear of homelessness.  Their worth only measured by the degree to which they either contribute to the maintenance of the economy, or at least to grease the wheels that allow ‘us’ to work from home, safe and secure. 

In my work with the concept of the subaltern, conceived of by Gramsci and developed and employed by postcolonial theorists such as Spivak and Bhabha it broadly refers to those considered oppressed and voiceless, typically minority social and ethnic groups. Until now the subaltern has tended to be represented by the brown ‘other’, and within a global health context with a genealogy traceable to colonial medicine through which such groups were pathologized as ignorant and unclean, and subject to a range of experimental treatments and controlled through the deployment of racial cordon sanitaire. Examples are legion and include the US led Yellow Fever interventions in Cuba, Panama and the Philippines were US interests were protected through the sanitation of colonial bodies (considered incapable of observing sanitary practices), interventions in ‘British Caribbean’ and southern India where populations infected with hookworm were ‘treated’ with highly toxic, painful and occasionally fatal worming medicines; and, in Australia, attempts to control the spread of venereal disease in Aboriginal communities led to proposals for the establishment of reserves, the idea ultimately rejected with the use of remote islands  the favoured option. These (and countless other) abuses have echoed through the ages, in no way a relic of another time, and have been manifest in myriad forms such as the sustained removal of blood samples from West Africa during the 2014-16 EVD outbreak by European and US Public Health agencies without the permission of either patients’ or local governments to the widely covered suggestion of French virologists that African communities would serve as useful test subjects in the development of a COVID-19 vaccine. Further, beyond these direct manifestations it is important to recognise the structural interventions of the global North and its institutions, notably the neoliberal Structural Adjustment Programmes imposed on developing countries during the 1980s and 1990s whose devastating effects on health infrastructure continue to contribute to negative health outcomes. 

With its global impact COVID-19 has revealed what I have termed, borrowing from Hobson, the state of ‘gradated subalternity’, whereby groups that hitherto would not have been considered characteristic of the ‘subaltern’ but whose circumstance has rendered them similarly denied agency, a voice, empathy and fundamental human rights. The ranks of the colonial subjects of the era of empire and the newly independent countries that emerged in the aftermath of the second world war have been joined by those who previously might have benefited from their ‘subalternity’, the disposable classes of the global North, people whose lives are increasingly characterised by the fragility and fear experienced by those in the South. In the 21^st century it is clear that the disposable class is truly global, an era in which limited access to, or even the denial of, healthcare and protection from health threats has added the western working classes and western based BAME communities to the burgeoning ranks of the subaltern.

Of course, these disproportionate impacts and outcomes in health on the poor and the subaltern have always been there, but perhaps COVID has made them all the more visible and ‘front and centre’, the effects of poverty, inequality and marginalisation, and their interactions with the virus have been so devastating and so immediate, so local and global. The question remains as to whether this will prompt an emergence of greater empathy and solidarity with those whose long-standing exploitation has benefitted ‘us’ in innumerable ways. Returning to Niemöller, COVID-19 has writ large the precarious and disposable status of most of us, emphasising that it’s really just a question of degree. As we wait eagerly for the announcement of a vaccine and luxuriate briefly in the promise of safety and a return to our version of normality it’s probably worth reflecting on the concept of scarcity and to question whether we will be deemed worthy recipients or categorised as disposable as those upon whose work and lives empire was founded. 

Colonialism was at its core an economic endeavour and colonial medicine valued the lives of the ‘other’, the subaltern, as less than those of the colonizers, their value only in their support of the rapacious economic extraction that fuelled the development of the Western powers. Government public health strategies, particularly those adopted in the UK and the US have increasingly prioritised the economy over the well-being of an emergent underclass, the new subaltern.  Further, and time will tell, it will be interesting to see how the allocation of any vaccines to emerge will be determined, presumably the degree to which any potential recipient is considered a ‘contributor’ to society (and by society I mean the economy) will prove a significant factor. I fear this will merely entrench the stratification, the gradated subalternity if you will, already emphasised so clearly by the outbreak. Evidently, the disposable are no longer the ‘other’, nor are they ‘over there’. They are here. And, if not already, soon they may well be ‘us’.