Introduction
In the field of “global health,” Footnote 1 a sense of discomfort with the status quo and the systems and practices it upholds persists.Footnote 2 This unease stems from the lopsided nature of power and resources to address health issues across the world.Footnote 3 The authors accept the view that a system is what it reproduces, regardless of its best intentions.Footnote 4 The concentration of disease and death amongst those with the least power to address them reflects clearly established causal links between inequitable systems and health outcomes,Footnote 5 which have precipitated agitations for rectification of global health injustice. This has culminated in the clamor to “decolonize” global health,Footnote 6 which has ranged from interrogations of the training practices of global health students and practitioners,Footnote 7 to recommendations of better practices within the field,Footnote 8 decentralization of power, and challenge to assumptions of expertise in the sites of practice and intervention.Footnote 9 Given that power is largely a function of means, some have made suggestions to fundamentally address how the flow of resources shape the global health agenda, while prioritizing certain voices over others.Footnote 10
Decolonization requires decentering hegemonic logics and praxis. Drawing from critical Third World Approaches to International Law (TWAIL) sensibilities,Footnote 11 we posit that fulsome decolonization of global health can only occur when those at the margins can exercise agency over their health circumstances, just like those at the center. In this essay, we argue that the Africa Centre for Disease Control and Prevention (Africa CDC) is an example of what that could look like. Additionally, we explore global health’s troubled colonial origins and examine the replication of coloniality through the COVID-19 response. Finally, we make a case for a regional approach and examine the Africa CDC as an early example of what that approach could look like.
Global Health’s Troubled Origins
Colonial conquest and the desire to better understand and mitigate the diseases of the “tropics” inspired the formation of the field of global health.Footnote 12 From the outset, two paradigms of global health emerged: one focused on preventing the spread of infectious diseases while continuing the expansion of capitalism and international trade; another sought to protect the colonial project against the diseases of the tropics.Footnote 13 The negotiation of a uniform sanitary code to control cholera, plague, and yellow fever that was deliberated upon by European powers did not contemplate the colonial subjects as part of that regime,Footnote 14 as the colonized subject was seen as less than colonials, whom the law sought to protect.Footnote 15
The World Health Organization (WHO) embodied the spirit of its predecessors—the Office of International Public Hygiene, the health section of the League of Nations—and marked the beginning of the present chapter of global health.Footnote 16 Unsurprisingly, the initial hopes of solidarity and a common approach to addressing global health challenges did not materialize. Rather, a pattern of hegemonic superiority that prioritized the health concerns of the West over the rest took hold.
Following World War II, Europe, still reeling from its losses during the war, and seeking to rebuild, could not have compromised U.S. beneficence through the Marshall Plan to challenge the U.S. role at the WHO.Footnote 17 Subsequently, Cold War tensions and the withdrawal of the Soviet Union and its vassal states, led to the domination of the WHO by America. U.S. hegemony over global health was exacerbated by ideological contestations around which approach to international health should be adopted; the social medicine principles embodied in the WHO constitution, or a confinement to the provision of “technical assistance,” preferred by the United States.Footnote 18 The WHO chose the latter, pursuing an approach of having limited objectives, and establishing an institutional structure of regionalization,Footnote 19 over direct relationships between states and the WHO. This pattern of agenda setting by more powerful actors has been baked into the praxis of WHO, even during the most dire global health crisis.
COVID-19 and the Replication of Colonial Structures and Priorities
The manifestation of a global health order which prioritizes capital and trade over peopleFootnote 20 was evident in the response to COVID-19. Confronted by an unprecedented global health crisis, the preferences of more powerful states caused a pushback on interventions intended to fast-track equitable access to life-saving vaccines for poorer states. The imposition of travel bans,Footnote 21 vaccine apartheid,Footnote 22 and resistance to capacity building by smaller statesFootnote 23 finally laid bare the deeply colonial and uneven nature of global health, vindicating prior calls to decolonize global health, and address the over-concentration of power in the hands of a few.
Considering weakening international cohesion, the rise of nationalism and nativism, and the imminent loss of the WHO’s longest and biggest funder (the United States),Footnote 24 appeals by the WHO for stronger global solidarity appear to ring hollow. Likely due to the constant prioritization of the needs of the powerful over others. Indeed, even attempts to rectify the mistakes of the global COVID-19 response and better prepare against future pandemics have resulted in a weak Pandemic Agreement that likely will not rise to the challenges ahead.Footnote 25 The weakening of human rights-based norms in the treaty in favor of non-binding principles with weak state obligations have resulted in the sacrifice of normative clarity for consensus; albeit one largely on the terms of the powerful. In recent post-COVID global health reform initiatives, the continuation of colonial logics is evident. As such, clear action toward the decolonization of global health is necessary. Beyond rhetoric,Footnote 26 piecemeal reform couched as decolonization, and the capture of the term and its aims,Footnote 27 decolonization through a region-driven paradigm like Africa CDC—rather than as a regional appendage of the WHO such as the Pan-American Health Organisation (PAHO)—can move the needle from symbolism to structural change.
The Africa CDC as an Early Example of Meaningful Decolonization
In January 2017, the AU launched the Africa CDC in Addis Ababa, Ethiopia.Footnote 28 The establishment of this autonomous regional health organization stemmed from legitimate concerns about the inadequacies of public health systems across the continent and their ability to effectively ensure disease surveillance and address existing, and emerging diseases with the potential to become pandemics.Footnote 29 Another motivation may have been the mishandling of the response to the 2014 Ebola outbreak by the WHO. In the wake of the Ebola epidemic, which affected much of West Africa from 2014 to 2016,Footnote 30 the lack of local preparedness and capacity, as well as the world’s initial indifference to the impact of the outbreak,Footnote 31 the need for an approach that prioritized regional agency over dependence on foreign actors became apparent.Footnote 32 African countries saw the need for an institution that could provide coordinated and integrated solutions through credible leadership that delegated authority and disseminated timely information, while carrying out operations transparently.Footnote 33
Since its creation, the Africa CDC has engaged in institutional norm making, creating standards that could potentially reinvent the field of global public health on the African continent. The Africa CDC has new structures and governance mechanisms, such as Regional Coordinating Centers across the four sub-regions of the continent;Footnote 34 and a new cadre of global health actors and professionals focused on strengthening public health systems across the continent. The African region has empowered the Africa CDC, while continuing to engage with the WHO system and the global health governance architecture under it. It has committed to collaborating with the WHO and other UN health agencies,Footnote 35 to leverage each organization’s strengths for the improvement of public health in Africa. We are witnessing an early example of a regional health governance approach, that in our view reflects a strategic structural ambivalence to the WHO-led global health governance regime.
A notable milestone took place on August 13, 2024, when the Africa CDC took the lead in declaring mpox a public health emergency of continental security, under its new emergency powers.Footnote 36 The WHO immediately followed suit by declaring mpox a public health emergency of international concern on August 14, 2024.Footnote 37 Only a decade earlier, the WHO found it very difficult to act in a similar manner in the context of the Ebola epidemic. We are left to conclude that the reason why the WHO suddenly found its voice is because it realized that to remain relevant to the Global South, it needs to start focusing on Global South priorities.
For the Africa CDC to fulfill its commitments to strengthen the continent’s pandemic preparedness, it must operate from a place of agency, drawing on inherent strengths, thus demonstrating what a decolonial praxis in global health could look like.
Conclusion
De-centering the foreign gazeFootnote 38 requires acts of self-sufficiency, shaped by local contextual realities and aimed at addressing them as such.Footnote 39 It requires an alternative centering of an Africanist vision,Footnote 40 enabled by systems and practices that operationalize the legitimate yearnings for self-determination and sufficiency. While concerted effort must continue to push back against the decline of international solidarity, the terms of said solidarity must be renegotiated from a place of strength and capacity, not of aid dependence, and hegemonic subservience. To truly fulfill its potential, region-driven health governance systems like Africa CDC require significant funding, while avoiding the socioeconomic and political pitfalls that led to the prioritization of more powerful voices to the detriment of Africa in the WHO. The decolonization work requires a detangling from the colonial center. The structural shift in global health foretold in the wake of EbolaFootnote 41 is here and the current “winds of change” offer the opportunity to do the kind of systemic work of reform that decolonization in its truest form requires. The Africa CDC offers insights into what such work can produce, as well as what more is required to truly decolonize the field of global health.
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