Excerpted From: Matiangai Sirleaf, White Health as Global Health, 117 AJIL Unbound 88 (2023) (55 Footnotes) (Full Document)


MatiangaiSirleafWith 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 health 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.” 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. 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.” They also imposed a cordon sanitaire that would segregate the city well after the 1914 outbreak of the plague in Dakar. Similarly, for the British colonial authorities in Sierra Leone, the preferred method of fighting malaria was residential segregation. Several analyses have demonstrated how sanitation concerns were used as a pretext for furthering segregationist ends. Tropical medicine took place in settings that often depended on the coercive power of the colonial administrative state to implement its interventions. 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. 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. 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. 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. 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. While many Black lepers were detained on Robben Island, white lepers were allowed to remain quarantined at home.

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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” 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. 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. 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.” 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.” 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, like equity, solidarity, and inclusiveness. 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.

Nathan Patz Professor of Law, University of Maryland School of Law, and Professor, Department of Epidemiology and Public Health, University of Maryland School of Medicine, College Park, MD, United State