Introduction
It all began with student protests at the University of Cape Town in post-Apartheid South Africa early in March 2015. Students demanded – and agitated for – the removal of a statue of Cecil Rhodes (1853-1902), the key figure in establishing British colonial rule in Southern Africa but also a generous benefactor of their institution. The students argued that Rhodes’ philanthropy veiled the cruelty of the exploitative colonial system to which he owed his riches. He, thus, became the impersonation of colonialism.1
This protest, dubbed “Rhodes Must Fall” spread quickly across the nation and abroad. At Oxford University, custodian of a huge scholarship fund endowed by Rhodes and having also a statue of his on public display, students protested likewise while scholars at Harvard Law School staged a similar protest that same year labeled “Royall Must Fall” aiming at the removal of their school’s shield honoring the memory of a family complicit in “the brutal torture and murder of 88 enslaved persons.”2 Between 2018-2020 working groups on “Decolonizing Global Health” were established at Duke and Johns Hopkins University, the Universities of Copenhagen, Stokholm, and Edinburgh. An invitation to a conference on “Decolonizing Global Health” by the Humanitarian Student Association at Harvard in February 2019, read: “Come join folks committed to a vision of global health that is equitable, reflexive, and anti-colonial … What does it mean to engage in this field [of global health] without acknowledging and tackling the history of colonial plunder? What does it mean to not acknowledge the role of global capitalism in generating the unequal conditions that manifests health and disease? … Our specific goals include: … Imagining alternative futures of ‘global health’ that can incorporate various non-hegemonic views including anti-imperialism and anti-capitalism … The conference will be a step towards creating a student community committed to a vision of global health that is equitable, reflexive, and anti-colonial in both delivery and discourse.”3
The call to decolonize medicine, global health in particular, “is greatly nuanced ranging from calls to reform ‘the system’ to calls for ‘disposing of it all together’” viewing health problems in low or middle income countries as the result of a “radicalized hierarchization of humanity and health systems, and exploitative neoliberalism.”4 While entertaining utopian visions and extremist views is the privilege of the youth and typical for students determined to make the world a better place, these protests were not just that. Sensing that there is more than mere polemics or protest their concerns received serious attention in articles published by renowned medical journals like the Lancet and the BMJ Global Health 5 unleashing a flood of topic related studies. To better understand this discussion some of its basic topics should be clarified first.
I. Some Principal Considerations
Provided the call for decolonizing global healthcare is not driven by ethnocentric ideology or nationalistic policy, it reflects a heightened, often discounted, awareness of issues implicit in any cosmopolitan endeavor like trade, travel, and diplomacy. Such awareness is not the least a reaction to living in a globalized world with the experience of the particularity of one’s own worldview. The confrontation with, sometimes the clash of different perceptions of what is right and wrong6 prompts the quest for self-affirmation and cultural identity.7
Cultures are manifestations of different time-tested tactics by larger social groups. They are handed down orally by elders, in sacred texts, and by traditional customs so that next generations get enabled to manage existential challenges and solve practical problems of their environment successfully. Environments, however, keep changing constantly due not only to ecological, economical, and social changes, but also to new discoveries and inventions which require the acquisition of innovative skills. If cultures lack dynamic adaptability and fail to adjust accordingly, they are doomed to oblivion.8
Infirmity, impairment, and disease present challenges plaguing humankind since time immemorial. No surprise, then, that every culture has developed strategies in combating maladies and protecting from harm to avoid untimely death.9 The study of this is the subject of medical ethnography, a subdiscipline of medical anthropology.10 Each of these strategies reflects the unique worldview of the community practicing it. This becomes evident in the explanation of the cause and etiology of diseases – by evil eye, demons, spirits, curses, God, gods, envy, virus/bacterium; in the treatment of sickness – chants, spells, herbs, medicines, sacrifices, prayer, spells, drugs, surgery; and in the professionals to be consulted like shamans, medicine men, herbalists, witch-doctors, prophets, sorcerers, physicians, and surgeons.
All nosology, diagnosis, and therapy are rooted in a distinct worldview and operate within that plausibility structure fairly effectively. Even if practitioners of rational-scientific medicine claim their praxis to be neutral and free from any overarching axiom, it is not.11 Rather, they just avoid explicit allusion to an overall frame of reference. Omitting reference to a meaning providing perspective, they work within a reductionistic set of parameters that limits the impact of their efforts which complementary or alternative approaches such as psychosomatic medicine, holistic medicine, whole person medicine, and the like attempt to compensate for.12 However, said reductionism has an indubitable advantage, too, namely the efficacious applicability of this medicine almost everywhere, unlike shamanistic procedures which are dependent on a shared worldview to become effective as they are practiced in Indonesia13, Korea14, South Africa15, among the Saami in Finland18, Native Americans in the U.S. and Canada17, and elsewhere.
While the plurality of therapeutic systems mirrors the diversity of cultures around the globe, it is without question that there exist great differences regarding the reliability of diagnoses and the outcomes of cures. For instance, when people in Ghana diagnose goiter as “witch-disease” and, fearing for the wellbeing of their community, seek to eliminate the goiter affected individual as soon as possible, (which, unfortunately, are mainly women)18, they render a culturally established sentence with horrible consequences for the unfortunate person. In contrast, if goiter gets diagnosed as what it is, namely iodine insufficiency treatable with substitute medication, the social stigmatization loses its grip and allows the patient to live on. Likewise with leprosy (Hansen’s disease), which since biblical times19 led to the expulsion of the diseased and their despicable treatment in many a culture up until pretty recently as in Japan.20 However, thanks to the discovery of the Mycobacterium leprae in the 19th century followed by the multi-drug therapy used today, this scourge of mankind lost its threat, too; it now can be healed.21 The same is expected to happen soon for people living with the human immunodeficiency virus (HIV).22
No doubt, modern/Western/allopathic/bio- or rational-scientific medicine is the most reliable healing system available today, the blessings of which nobody wants to forego. Its strength lies in diagnostic soundness and effective treatments thanks to methodological, evidence-based research, potent drugs, hygiene, and/or surgery for countless diseases, albeit not for all.23 The reductionism ingrained in Western medicine yielded – and keeps yielding as in genetic medicine – astonishing results for better understanding the cause of diseases and their successful treatments. This efficacy is owed to pivotal discoveries resulting from the unrestrained study of nature, human nature in particular, its anatomy, physiology, and pathology aided by pharmacological inventions and surgical skills. These developments happened to come about in Western culture due to a principal change in attitude towards nature. Researchers were not any longer afraid of a looming revenge by spirits or the wrath of the guardians of nature like the gods of fauna and flora. English statesman, philosopher, and Attorney General Francis Bacon (1561-1626), in 1620, programmatically proclaimed: “The secrets of nature are better revealed under the torture of experiments than when they follow their natural course.”24 His younger contemporary, French philosopher, scientist, and mathematician René Descartes (1596-1650) declared that the human body – not the human being! – is a machine devoid of a soul allowing for its unrestricted dissection25, something which in the Celestial Empire of China was permitted only in the early 20th century.26
Such kind of thinking paved the way for autonomous investigative research unfettered by cultural, religious, philosophical, or ecclesiastical restrictions, gaining full momentum in the 18th century, commonly known as the age of European Enlightenment. Scientia, that is wisdom, nurtured by knowledge mainly based on traditional texts, so morphed into science, knowledge, based on rational experiments and their astute evaluative observation by critical minds. Truth was not revealed any longer in holy Scripture and hallowed tradition studied and explained by the learned. Truth then got steadily revealed by discoveries resulting from methodical, controlled experiments and their judicious analysis by rational reasoning. Thus, science became synonymous with the search for truth. Being excited about all their new findings and discoveries enabled by this approach, researchers perceived their work quite literally as acting like “priests” in the “temple of science” where their colleagues gathered as devoted “worshipers” to celebrate newly obtained knowledge as “revelation” of ultimate “truth.”27 The Nestor of cellular pathology, eminent German physician and healthcare politician Rudolf Virchow (1821-1902), before a huge audience of staunch scientists in 1865, unabashedly confessed: “I openly admit that science has become our religion.”28 Thus, what Francis Bacon still regarded to be a religious pursuit for the benefit of humanity, namely to regain anew the “dominion over creation” (Gn. 1:28) lost in the fall, became in the course of time an entirely secularized venture – as we know science and medicine to be nowadays.
Even though they have a long-standing tradition and show notable results, neither Acupuncture nor Unani, neither Ayurveda nor Traditional Chinese, but rational-scientific medicine obtained global dominance despite her well-known shortcomings. Her principles serve as rationale for policy decisions of the World Health Organization (WHO), its advising and material assistance29, while the categorization of maladies listed in the International Classification of Diseases (ICD) uses the nosology and taxonomy of biomedicine, which, however, does not work regarding so-called Culture Bound Syndromes (CBS) specific to particular societies.30 The impact of rational-scientific medicine entails the education of experts in medical schools and professional training in colleges of nursing. It also comprises family medicine, community health, disease prevention, hospitals, laboratories, rehabilitation centers, and healthcare insurance plans, too. Maintaining and running such highly complex system is costly and, therefore, unaffordable for economically strained populaces.31
But the plea for decolonizing global healthcare is also caused by reactions to public healthcare measures regarding behavioral directives issued by governments to control epidemics. To stop the spread of an infectious disease, people are asked not to have any physical contact with contagious individuals infected with a virus, to abstain from intimate contact with them, and to stay away from their bedside if not protected properly. When such patients die, their bodies must be safely disposed of, which violates basic cultural norms to be observed at burials by the communities so not to anger the spirit of the dead and inflict harm on the wellbeing of family and clan. Therefore, if the need for healthcare measures is not communicated well enough that it can be understood truly by the population involved, certainly the advice will not be heeded, or, as in the case of vaccination, the offer will be viewed with suspicion, if not refused straightforwardly for fear of poisoning. Taking the Ebola epidemic of 2013/2014-2016 as an example: to prevent the disease from spreading, precautionary measures had to be taken, like avoiding handshakes and hugs, the isolation of infected people from their families, and the burial of the deceased in hygienically sealed bags or coffins without the performance of traditional burial rites.32 Likewise, during the Covid-19 pandemic Sri Lankan Muslims were ordered “on hygienic grounds” to cremate their dead instead of burying them according to Koranic instruction.33 Misguided healthcare policies in South Africa contributed to the disastrously high rate of HIV infections and AIDS prevailing in that country. Since HIV was seen as an American invented bioweapon, and AIDS as “a disease of racism” and “a fabrication foisted on Africans by whites,” HIV testing was stopped and antiretroviral drugs banned as ineffective, harmful, even poisonous, while their promotion by the WHO and the scientific medical community counted as serving exploitative interests of multinational pharmaceutical companies.34 The acronym, AIDS, was undone polemically as “American-Invented-Disease-Syndrome”, or, more sarcastically, as “American-Invention-[to]-Discourage-Sex”.35 Unfortunately though, this kind of ideologically tainted conspiracy theory still lingers on, making young Zulus raised in a vitality-promoting culture refuse to follow medical advice regarding the prevention of HIV.36
The rejection of the hegemony of biomedicine operative in public health measures is, however, not only fueled by behavioral instructions conflicting with established cultural norms, or by the fear of poisoning when inoculated, or by the suspicion of being a target for American biowarfare, or of exploitation by pharmaceutical companies when taking non-indigenous medication and drugs. The rejection is also driven by more fundamental concerns like the quest for a fuller epistemology of disease etiology37 and a general criticism of the concept of global public health, charging it with perpetuating colonialism in the very way in which health issues get addressed and by whom.38 The call for decolonizing medicine and its accompanying epistemology, thus, is multifaceted. While it insists on deconstructing the overall socio-political context of global healthcare, it also demands an honest reconsideration of the ways and means of communicating successfully about life saving measures in inter-cultural settings with competing healthcare systems. In times of an acute crisis this becomes a question of life and death.
II. European colonialism and Christian missions
Besides highlighting issues to be conscious of when discussing decolonization of medicine and global healthcare, this discourse, to become really meaningful and honest, also requires some knowledge of the intermingling of colonialism and Christian missions, because European colonialism and Christian missions have been intertwined closely for centuries. In fact, the very concept of mission, understood as proclaiming the Gospel to non-Christians, to teach and baptize them, emerged within this very context during the 16th century.
Spaniards and Portuguese were the first to establish colonies in transoceanic places, east and west, where entrepreneurial seafarers and explorers supported by the authority of royalty put up guarded settlements as stations for trade, claiming the sites as property of their crown and ruled by the law of their home country.39 Their strong ships and their guns granted them superiority. When Columbus, in 1492, reached the West Indies and later the Americas, unknown to Europeans until then, a conflict arose between Spain and Portugal about authority over and ownership of newly discovered territories, not minding rights and concerns of the people living there. The conflict got resolved in the Treaty of Tordesillas (1494) which divided the western Atlantic hemisphere along a meridian at about 49o W, allotting all territories west of it to Spain and those to the east to Portugal. A like agreement was struck later in the Treaty of Zaragoza of 1529 dividing the eastern Pacific hemisphere along the 142o E antemeridian, with Portugal getting all lands west of it and Spain the eastern parts.40 These treaties sealed the division of the world (divisio mundi) and created a reality, the consequences of which are still noticeable today in cultures and politics.
Besides satisfying the greed for accumulating wealth and the craving for power along with control, the treaties of Tordesillas and Saragoza also charged the Iberian monarchs with the obligation to make the Gospel known, to teach and baptize those who by virtue of invasion had become their subjects. In 1522, Pope Hadrian VI entrusted the privilege of ecclesiastical commissioning for ministry, the missio canonica/missio apostolica to the patronage of the sovereigns of Spain and Portugal who then appointed their priests for service in overseas colonies. Soon “the meaning of the term ‘missio’ changed from referring to this act of authorization to referring to the entire activity of the messengers of the faith. Eventually, it also was used to describe the territory in which this activity took place. Thus, the messengers of the faith became missionaries. Their work was described as their missionary work …”41
Portugal spearheaded the colonial enterprise trailed by Spain, Denmark, France, the British, and others. At the height of European colonialism, the Berlin Conference of 1884/85, also known as the Congo Conference, divided – without any African participation – Sub-Saharan Africa among those powers which had “protectorates” there, bringing 90% of that continent under European control.42 Still, the full extent of the colonial enterprise can only be realized when computing the numbers of satellite regions ruled by European powers one time or the other, namely United Kingdom 115, France 53, Portugal 52, Spain 44, The Netherlands 29, Germany 20, Russia 17, Denmark 9, Sweden 8, Italy 7, Norway 6, and Belgium 3.43 The reversal of colonial hegemony, oftentimes occasioned by bloody revolts and freedom fights, began with the Declaration of Independence by the English colonies in North America in 1776 and the gradual collapse of the Spanish Empire during the 19th century commencing with the independence of Chile in 1810, of Argentine in 1816, and of Brazil in 1822/1825. European colonialism crumbled fully after World War II with more and more countries obtaining independence as did India in 1947, Ghana in 1957, and many others.44 Hence, the era of European colonialism, geographical colonialism that is, lasted for about half a millennium, not minding some remnants today even though colonialism was banished for violating human rights by the UN General Assembly in 1960.45 However, the impact of colonialism on non-European cultures endures46 making some speak of “coloniality”47 defined as “conceptual apparatus … to capture the racial, political-economic, social, epistemological, and gendered hierarchical orders imposed by European colonialism that have transcended “decolonization” and continue to oppress in accordance with the needs of pan-capital … accumulation.”48
The alliance of European colonialism with Christian missions was very strong most of the time. This had to do with the Christian imprint on European culture since the 6th century shaping public, social, and family life alike by the ordering of time (calendar) and the concept of law and political power. Europeans were Christians, at least nominally, taking Christianity along into the colonies, while explicit missionary activity was dependent on permission by the colonial authorities and local rulers which was not always granted, as was the case in India up to 1813.49 It seems, however, that such dependency did not pose a serious issue to missionaries, except for a few50, while concerned Christians back home protested slavery51 and the opium trade.52
The farther European colonization extended the more intensive missionary work was pursued. In 1792, British Baptist, William Carey (1761-1834), published his Enquiry into the Christian Obligation to Use Means for the Conversion of Heathens sparking enthusiasm for missions in lay people by referring to Matthew 28:18-20 as authoritative text.53 In the political climate of absolutism, this call to submit to a charge by the ultimate authority, God, was enthusiastically received. Later, in June 1836, missionaries serving in the Hawaiian Islands issued their widely read appeal “The Duty of the Present Generation to Evangelize the World,” which in 1904, rephrased by John R. Mott (1865-1955) as “The Evangelization of the World in this Generation,” became the watchword of the Student Volunteer Movement.54 The sense of unquestioned duty and urgency along with an innocent euphory about the technical feats of the industrial revolution and its accompanying economic growth – not the least due to colonial exploitation – led to exponential increase in missionary personnel. Their imperial ambition and cultural haughtiness are indicated by publications like “The Christian Occupation of China”55 and “Christian Missions and Social Progress”56 to name but a few. Eminent missiologist, Kenneth S. Latourette (1884-1968), hailed the colonial era of 1800-1914 as “The Great Century” of Christian missions57, whereas Stephen Neill (1900-1984) a quarter of a century later took a more critical stance in his book on Colonialism and Christian Missions of 1966. In it, he notices with some regrets that the majority of missionaries did not object to colonialism due to anxiety, ignorance, or even appreciation for the superiority of European/North American culture and politics; only very few “lonely” voices condemned it.58 Conceiving their work as “spiritual ministry” catering to the “soul” of people otherwise lost to “eternal damnation,” why should missionaries bother about politics at all? Should they not? Whatever, not being able to deny any longer the mutual interdependency of Christian missions and colonialism, how does this affect global Christian healthcare work today?
III. Christian Mission and Global Healthcare Work
In the early times, missionaries experienced illness and disease wherever they went, not just regarding their own health when exposed to tropical climates, but also when meeting the people to whom they were sent. The medical help they could provide was quite limited due to Church regulations prohibiting the practice of medicine by religious orders59 and the little relief they could actually offer. Working in Paraguay, Dominicus Maier SJ (1689-1767) reported: “Sometimes our love for these people and their need … compel us to function as physicians for them. Necessity often taught us how to bleed them and how to pull teeth – even though we had no training in these skills. With God’s help, I myself often treated broken bones, cancer, and similar accidents and illnesses.”60 In the colonies of Portugal, lay societies, Misericórdias, were organized to care for sick military and business personnel in “hospitals,” comparatively small institutions of the most varied kind with just twelve, sometimes eighteen beds, housing sick, needy, and destitute people, and, only reluctantly, offering their services to indigenous patients as well. In the Spanish territories, the Consejo de las Indias, the central administrative body ruled that “a hospital for the care of poor and sick [is] to be built next to the church in every village,” to be constructed, maintained, and run by members of the native community in place so that these institutions become owned by them.61 However, caring, not curing, was the task of these institutions.
That changed dramatically once the therapeutic power of rational-scientific medicine became known and available. The second half of the 19th century saw the beginning of a time of epoch-making discoveries in medicine, surgery, hygiene, and pharmacology: In 1846, anesthesia was successfully used in an operation for the first time, thus opening new possibilities for surgery, which, aided by the discovery of antisepsis (1847/1867), saved the lives of countless patients, unnumbered newborns, and their mothers. Hygiene and the linkage between epidemics and sanitary, ecological, and economic conditions also became understood, based on which the social and political dimensions implicit in healthcare became apparent, which, consequently, led to the establishment of departments of public health from 1876 onward. Finally, cellular pathology and bacteriology, thanks to which epidemics could effectively be offset at the level of their causation with potent drugs and sera, were further demonstrations of the effectiveness of rational-scientific medicine. It enabled the cure of many diseases – malaria, typhoid, yellow fever, diphtheria, plague, typhoid, leprosy – which plagued humankind since primeval times.62
Christian doctors fully shared the euphoria about the newly acquired potential while some of them steeped in the Revival movement instantly realized the responsibility inherent in those blessings. The God given power to heal by means of this medicine, they held, cannot be denied anyone in need of it, be they near or far. God had entrusted this power to the Christian world to be shared, not to be kept and exploited for personal gain. Therefore, all who resist or deny the “call of suffering,”63 because of indifference, will have the deaths of millions on their consciences.64 Even though only a fraction of mission societies took this call to heart,65 medical missions had such an effect that in 1900 someone could label it “the heavy artillery of the missionary army,”66 because the numbers of initial contacts with local people established by medical missions were more than twice compared to all other missionary activities in schools, orphanages, seminaries, and churches combined, albeit only a fraction of missionary personnel worked medical stations.67
But the impact of medical missions reached far beyond the encounters with individual patients. Its representatives engaged also in disease prevention schemes and in issues concerning social and behavioral reform. Medical missionaries made significant contributions to public health by introducing smallpox vaccination programs and caring for clean drinking water along with the proper disposal of sewage. Together, with others, they campaigned for the abolition of opium smoking and the binding of women’s feet in China, while lobbying in India against child-marriage, Sati, and female infanticide. The training of national men and women in medicine and nursing was yet another facet of the impact medical missions had on the cultures of their host countries. Such training imparted to the students the principles of the rational-scientific approach to sickness and therapy and an understanding of professional care for patients irrespective of family or clan ties. Medical missionaries also built hospitals, pharmacies, and dispensaries, organized professional associations, and initiated the publication of professional journals, all this modeled on the patterns existing back home in Europe and North America. No doubt, Christian medical missionaries thereby became active agents in the intercultural transfer of standards and values, which might well justify the charge of colonialization, at least to a certain degree.68 Do these achievements need to be decolonized?
It is not just some fancy attitude of later generations to evaluate critically the achievements of those who have gone before. This, rather, is an essential process in genuinely taking possession of what got inherited from the progenitors. What appears to be alien becomes suspicious and must be scrutinized to see if it is a superimposition from outside. Yet, the distinction of what is foreign to a culture and what is not requires awareness of cultural roots nurtured by narratives told, images seen, and customs practiced. But, as mentioned above, cultures cannot stay alive by protectively shunning the coming to terms with the actual challenges of the times, nor keeping to themselves in isolation.69 Cultural identity is not won by anxiously clinging to the past but by actively engaging the legacy of the past in solving the problems of the present like facing the still grim reality of disease and of untimely death.
Conclusion
Today, rational-scientific medicine is present globally and works for the good of people most of the time. Therefore, to demand its decolonization cannot mean to get rid of it. Rather, insisting on the decolonization of medicine is to be understood as a demand to consciously take into account the colonial and imperialist baggage whenever engaging in global healthcare and to cultivate dialogue about the principles informing any action taken. This requires commitment to a communicative process in which people with diverse mental concepts coming from different backgrounds informed by distinct core values and unique narratives participate. This is an arduous process indeed. It involves acquiring accurate knowledge about worldviews across cultural divides, familiarity with global, colonial, and local history, with the regional language, and the willingness to listen attentively even when criticized and being questioned.70
In the final analysis, it seems that the demand to decolonize medicine hints at the fact that practitioners of rational-scientific medicine engaged in global health in the past, Christian or not, failed to seriously engage in cross-cultural dialogues about what they were doing. The positive results of their interventions appear to have justified their actions without needing further justification. But the naiveté of ignoring the macrostructure of their activities framed by socio-political and economic realities rooted in a colonial past is contested today rendering the idea of innocent philanthropy in global healthcare fictitious. Confronted with this reality, Christian healthcare workers are painfully reminded that they, too, cannot escape the grip of sin despite all honest efforts and sacrificial commitment; after all, they also live still in a fallen world. Yet, they will not despair nor become apologetic. They will instead passionately cultivate and engage in intercultural dialogue to identify health issues and respond to healthcare needs. They will do so not with an attitude to teach others what is right or wrong but for obtaining true understanding so to enable common action for bringing about genuine healing. It is high time to get moving along this path with eyes and ears, hearts, and minds wide open.
Competing Interests
None declared.