Who Gets to Heal the World?

Global Health often presents itself as a project of cooperation and shared responsibility. Yet the systems beneath that narrative reveal a more complicated reality. Many of today’s institutions, priorities, and funding models were shaped by colonial Public Health systems that managed populations, extracted knowledge for imperial benefit, and imposed outside structures and practice. These foundations were never properly dismantled, and their influence is becoming increasingly visible. The inequities we see today are not accidental, they are inherited. When the United States cut aid programmes in 2025, this endangered core health programmes across the Global South. Their fragility was not a surprise but a reflection of how deeply unequal the system remains. To understand this vulnerability, we must confront the colonial logic that still underpins Global Health today.

Colonial Foundations of Public Health

Colonising states built Public Health systems to govern, not simply to heal. In the Philippines, US officials used sanitation drives and disease surveillance to classify and discipline local populations and presented enforced policies as scientific necessity. Similar patterns appeared elsewhere: British authorities in India imposed harsh plague controls on Indians but not Europeans, while health interventions in the Belgian Congo often relied on coercive practices. Sleeping‑sickness campaigns, for example, involved forced medical examinations and the relocation of entire communities. Colonial authorities also frequently compelled communities to participate in sanitation or disease-control work. Across empires, medicine reinforced racial hierarchies and justified intrusive interventions.

The United States applied these practices throughout its own empire. Territories such as Puerto Rico and Guam were used as testing grounds for techniques of population management. Puerto Rico became a laboratory for early contraceptive pill trials, by enrolling poor and working-class women without proper oversight or consent. Sterilisation programmes disproportionately targeted racialised and low-income communities, while Native American women on the mainland faced non-consensual procedures well into the 1970s. These interventions laid foundations for today’s inequalities within Global Health.

Systems that Survived Empire

Upon independence, many countries found themselves with health systems designed for social control rather than for building resilient primary care.

Institutions built on inequality tend to reproduce it: fragmented services, external dependence, as well as chronic underfunding became defining features of many post‑colonial health care systems. Early World Health Organisation (WHO) programmes, which were still shaped by Western advisers, prioritised narrow interventions over long‑term capacity‑building and kept technical expertise and authority firmly in the Global North.

Colonial medicine also entrenched a hierarchy of knowledge that outlasted imperialism. Western biomedical expertise was elevated as the only legitimate form of care, while indigenous healing systems were sidelined or even criminalised. This dismissal of local knowledge persisted after independence: many countries retained health structures that offered little space for traditional healers and their practices, even though these were often better attuned to local needs. This resulted not only in a profound cultural loss, but also in a long-lasting mistrust in the systems that failed to recognise people’s own ways of healing. This legacy of exclusion appears not only in treatment but in the very question of who gets to produce knowledge.

Contemporary Knowledge and Authorship

Medical colonialism also shapes who is recognised as an expert. As Seye Abimbola notes, Global Health still privileges the “foreign gaze”. Meaning that Western institutions keep defining the problems, as well as the solutions to them. This hierarchy did not disappear with independence; it gradually blended into the structures that produce Global Health knowledge today.

Major journals and grant programmes oftentimes disproportionately favour researchers based in the Global North. Even when studies take place in the Global South, their authorship, data ownership, and agenda‑setting remain controlled by Northern institutions. Clinical trials are increasingly conducted in countries with weaker regulatory protections, where companies face lower liability and less stringent ethical review than in high-income settings. These conditions make Southern contexts attractive for testing interventions that may not ultimately benefit local populations. The assumption that expertise lies elsewhere persists, thereby limiting the leadership of local researchers and organisations.

Donor Power and the Fragility of Institutions

These patterns are reinforced by global governance structures. Multilateral bodies such as the WHO, Gavi, and the Global Fund rely heavily on donor financing, giving high-income states and large foundations substantial influence over priorities and outcomes. Countries most affected by disease often have limited say in how programmes are designed or evaluated. This system works—until it doesn’t. When political winds shift in donor countries, Global Health programmes can change rapidly, leaving dependent health systems exposed.

This fragility became clear in 2025, when proposed US foreign aid cuts threatened essential programmes across the Global South. For many countries the risk was immediate: decades of externally driven priorities had left national systems underfunded and reliant on donors for basic services like HIV treatment, maternal health, or vaccine delivery. Sudden withdrawal and frozen funds exposed the cost of long-standing dependency. Communities that had never been supported to build strong, autonomous systems were now facing disruptions created far beyond their borders.

Without Power Shift, Nothing Changes

The history of medical colonialism makes evident that today’s Global Health inequalities are not accidental; they grew out of structures that were never fully dismantled. Public Health systems shaped by racial hierarchy, extractive research, and narrow, donor-driven priorities continue to limit local ownership and define which voices matter. In times of weakened multilateral cooperation and shrinking humanitarian budgets, these structural weaknesses have become harder to ignore, particularly for the countries long denied the chance to strengthen their own health systems.

Decolonising Global Health therefore requires more than new treaties or expanded participation. It means shifting power, valuing local expertise, and supporting health systems that are led and shaped by the communities they serve. Without these changes, Global Health will continue to reproduce the very inequalities it claims to address.

Written by Sarah Czernin, Edited by Sarah Jiayi Drogies

Photo Credit: Anna Shvets (Uploaded 14 May, 2020) on Pexels