With the expansion of European imperialism, public health concerns became globalized, necessitating cooperation with other imperial powers for the treatment and prevention of diseases. This essay traces the role of race and racism in the development of global public health law. It explores the connections, legacies, vestiges, and important disjunctions between tropical medicine and global public health, and considers the primacy given to white healthFootnote 1 as one of the animating purposes behind the emergence of the global public health regime. The centrality of protecting the health and interests of white people then and now continues to inform the global health agenda. This essay surfaces the role of international law through omission and commission in structuring and reifying racialized hierarchies of care and concern. It concludes that transformational reforms aimed at addressing this legacy are necessary.
Tropical and Colonial Medicine
Tropical medicine was a crucial aspect of colonial subjugation and expansion. For example, French colonial authorities in Senegal used the bubonic plague to further segregationist ends by closely linking the Black population to the disease, since they conceived of Black people as a “barbaric collective that threatened the order and health conditions in the ‘European’ city.”Footnote 2 In previous work, I define the “racialization of diseases” as the attachment of racial meaning to ailments based on the racial groups that tend to be socially associated with a given illness.Footnote 3 Consequently, even though the infection rate among Black Africans was not any higher than any other racial group, French authorities imposed harsh measures in Senegal, which included “burnings of huts, along with the formation of quarantine camps.”Footnote 4 They also imposed a cordon sanitaire that would segregate the city well after the 1914 outbreak of the plague in Dakar.Footnote 5 Similarly, for the British colonial authorities in Sierra Leone, the preferred method of fighting malaria was residential segregation.Footnote 6 Several analyses have demonstrated how sanitation concerns were used as a pretext for furthering segregationist ends.Footnote 7
Tropical medicine took place in settings that often depended on the coercive power of the colonial administrative state to implement its interventions.Footnote 8 Tropical medicine was generative for colonialism. As advances took place in the field, it furthered imperialist ends by enabling troops to better cope with unfamiliar diseases to be healthy to fight Indigenous populations resisting colonial domination and subjugation. Unsurprisingly then, tropical medicine grew to specifically focus on vector-borne diseases and infectious disease control, since these diseases had the greatest implications for the expansion of colonial empires.
Additionally, efforts to improve the health of subordinated populations in internal or external colonies were explicitly tied to racial capitalism, wherein being usable and being a thing of importance is a functional relationship between dominant and subordinated groups.Footnote 9 States arguably only developed public health systems to improve the ill health of Black, Indigenous, and other people of color as scientific knowledge expanded to confirm that germs know no color line.Footnote 10
Because disease carrying microorganisms do not differentiate among their victims, those concerned for white health could not afford to ignore Black health. Jim Crow laws in the United States could not prevent germs from measles, tuberculosis, pneumonia, or typhoid from spreading, which necessitated action that included historically subordinated groups in public health interventions.Footnote 11 In South Africa, concern for the health and wellness of Black people was driven primarily by their proximity to the white population and the potential negative impact that this might have on white interests.Footnote 12 For example, because leprosy was perceived to be a “Black disease,” harsh measures were enacted that allowed for compulsory segregation of all lepers due to fears that the disease was spreading and affecting whites.Footnote 13 While many Black lepers were detained on Robben Island, white lepers were allowed to remain quarantined at home.
Colonial Medicine to Global Health
In the first part of the twentieth century, there were about thirteen international agreements on global health.Footnote 14 Colonial powers prioritized global health because they wanted to coordinate sufficiently restrictive quarantine regulations that would facilitate the unimpeded expansion of imperial trade without exposing their populations in the mother country to diseases from colonial territories.Footnote 15
European colonizers prioritized defensive measures against contagion from racialized and “diseased” territories when formulating the global health regime. Adrien Proust, one of the leading French voices during the International Sanitary Conferences, authored several works on “the defense of Europe” against exotic diseases.Footnote 16 The 1892 Convention solely addressed cholera due to concerns that the Suez Canal could be a conduit for the introduction of cholera from India to Europe.Footnote 17 Consequently, the 1893 Convention required state parties to inform each other without delay if any outbreaks of cholera occurred within their territories.Footnote 18
Additionally, European powers feared that Muslim pilgrims returning to Europe posed a serious threat, following a cholera epidemic in Mecca.Footnote 19 The Sanitary Convention of 1894 was thus singularly dedicated to the pilgrimage to Mecca.Footnote 20 Similarly, following a serious epidemic of the plague in India, some Europeans were anxious that their other colonial territories might be affected.Footnote 21 Subsequently, the International Sanitary Convention of 1897 added the plague as a disease warranting international prioritization and notification.Footnote 22
These treaties exemplify how colonial powers shaped not only the emergence of the global health regime, but what diseases deserved international attention and prioritization. This was also reflected in the International Sanitary Convention of 1926, which modified the 1912 Convention and required international notification for the first confirmed cases of cholera, the plague, yellow fever, as well as smallpox and typhus.Footnote 23 Notably, there were millions of cases of typhus in Poland and the Soviet Union following World War I. The expansion of the list of diseases that deserved international recognition under the 1926 Convention coincided with the importance given to these diseases in the Global North.
During the 1930s, the Aedes aegypti mosquito was endemic in parts of southern Europe, and several outbreaks of dengue arose as a result.Footnote 24 Subsequently, thirteen European countries agreed to prioritize the prevention of the spread of dengue under the International Convention for Mutual Protection Against Dengue.Footnote 25 It was not as if diseases prioritized by these treaties were the only diseases afflicting populations globally.
Members of the new League of Nations also endeavored to “take steps in matters of international concern for the prevention and control of disease.”Footnote 26 Yet, commentators concluded that, “as compared with what it has done for other parts of the world . . . the Health Committee of the League of Nations itself has done remarkably little for the African continent.”Footnote 27
It was not until the 1944 modification of the International Sanitary Convention that the global public health regime began requiring state parties to send epidemiological information for diseases not pre-ordained as significant by Western capitals.Footnote 28 Under the 1944 Convention, state parties were to send so far as possible regular notifications of communicable diseases in their countries.
The multiple overlapping obligations from earlier conventions led to a complex situation where some states were parties to some instruments and not others.Footnote 29 In 1969, the WHO Health Assembly revised, consolidated, and renamed the International Sanitary Regulations the “International Health Regulations.” The basic premise of the system remained the same––notification requirements for named infectious diseases, which would then trigger an international response that imposed travel and trade restrictions to contain the spread of disease. While the names of the treaties and the substance changed incrementally over the years, the prioritization of white interests in their enactment remained constant.Footnote 30
Back to the Future
Unlike predecessor institutions, the World Health Organization was to be global not just in name but in substance. Its constitution states that, “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”Footnote 31 Yet, the current regime under the 2005 International Health Regulations does not refer to historic or ongoing racial discrimination in public health or medicine.Footnote 32 This failure to engage explicitly with race obscures the role of racism and subordination in global health.Footnote 33
The Regulations ignore the structural conditions in the international system that give rise to and limit the ability of states to develop core capacities. The Regulations assign primary responsibility for implementing health measures to combat infectious diseases to national authorities.Footnote 34 State parties have a legal obligation to develop better functioning health systems to detect, surveil, report, verify, and respond to disease;Footnote 35 and are also legally obligated to cooperate to help build health capacities.Footnote 36 Yet, the Regulations do not specify how this should be operationalized. Thus, legacies of subordination and continued inequities that have rendered states vulnerable to epidemic and pandemic diseases are unaccounted for in the Regulations. Regrettably, some of the proposed amendments to the Regulations from the United States tend to narrowly focus on bolstering early detection efforts without sufficient attention to historical vulnerabilities and lack of capacity.Footnote 37
Moreover, the present system provides state parties with substantial opportunity to make choices shaped by implicit or explicit racism. For example, during the COVID-19 pandemic, some states made decisions informed by “outdated but persistent settler-colonial conventions that have mapped illness and disease on to racialized peoples and certain geographic regions.”Footnote 38 The World Health Organization declared COVID-19 a public health emergency of international concern on January 30, 2020, and consistently “advise[d] against the application of travel or trade restrictions to countries experiencing COVID-19 outbreaks.”Footnote 39 However, by February 27, 2020, thirty-eight countries had already reported measures “that significantly interfered with international traffic in relation to travel to and from China or other countries, ranging from denial of entry of passengers, visa restrictions, or quarantine for returning travelers.”Footnote 40 A newspaper in France even carried the headline “Yellow Alert” on its front page.Footnote 41 Moreover, the understanding of the disease as racialized and “foreign” constrained the space for consideration of community transmission within the United States.Footnote 42 The racialization of COVID-19 led to public health law and policy decisions that assumed that the virus was engaged in racialized transmission efforts, checking documents and nationalities to determine whom to infect next.Footnote 43 This was evident in the overreliance on blanket travel bans as a magical solution to stop the spread of a highly infectious novel disease concomitant with the lackadaisical approach to implementing screening measures at airports in the United States and elsewhere.
Early reactions were not merely efforts at disease containment. The racial and colonial logics influencing COVID-19 law and policymaking were evident in innumerable ways throughout the course of the pandemic. A prime example, was the swift decision by countries in the Global North to cut off southern African countries following South Africa's genomic sequencing of the Omicron variant.Footnote 44 Instead of being rewarded for tracing and alerting the world to a variant that was already circulating in continental Europe,Footnote 45 the United Kingdom, and the United States,Footnote 46 the European Union and others were hasty to make decisions informed by “Afrophobia,” as the president of Malawi termed it.Footnote 47 One newspaper published a literal depiction of the racialization of diseases—replete with brown viruses with exaggerated phenotypical Black features traveling on a boat with the South African flag toward European shores.Footnote 48 This fear of the racialized other and their diseases is a powerful reminder of how the history of diseases and responses to diseases is linked to politics of racial exclusion and subordination.
Conclusion
The COVID-19 pandemic has created an opening to not only recognize, but to potentially reshape the relationship between race and global health. Early efforts to draft an international treaty for “pandemic preparedness and response to build a more robust global health architecture”Footnote 49 provide some possibilities.
In earlier work, I argue for the expansion of the common but differentiated responsibilities principle to the challenges posed by highly-infectious diseases.Footnote 50 The principle has two main elements: (1) common responsibility describes the shared obligations of two or more states towards the protection of a particular resource; and (2) a range of different burden-sharing arrangements that take into account each nation’s particular circumstances, especially its ability to prevent, reduce, and control the problem.
Encouragingly, the WHO's Conceptual Zero Draft released in February 2023 embraces the principle of common but differentiated responsibilities and capabilities in pandemic prevention, preparedness, response, and recovery of health systems.Footnote 51 The Zero Draft clarifies that “States that hold more resources relevant to pandemics, including pandemic-related products and manufacturing capacity, should bear, where appropriate, a commensurate degree of differentiated responsibility.”Footnote 52 It stipulates that prioritization is “required of the specific needs and special circumstances of developing country [p]arties, especially those that (i) are particularly vulnerable to adverse effects of pandemics; (ii) do not have adequate capacities to respond to pandemics; and (iii) potentially bear a disproportionately high burden.”Footnote 53 If operationalized, this principle could help address issues of racialized structural inequities in ways that other frameworks do not. The Zero Draft embraces other principles that would help to address past and continuing effects of racism in global public health,Footnote 54 like equity, solidarity, and inclusiveness.Footnote 55
It remains to be seen whether reforms will be truly transformational. My hope is that bourgeoning efforts to decolonize global public health and to address racial inequities will not be ephemeral.
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