Simplice Ayangma Bonoho, on WHO's mixed legacy in Africa

“The legacy of colonialism still pervades global health and sanitary policies in Africa and elsewhere.”

Winner of the first Lombard Odier Prize, awarded last week by the Geneva-based Forum suisse de politique internationale (FSPI) for his research into WHO's actions in Africa, historian Simplice Ayangma Bonoho tells The Geneva Observer that, in his view, the legacy of colonialism still endures in the definition and implementation of global health and sanitary policies.

On Sunday, the World Health Assembly, WHO’s governing body, will open its Seventy-fifth annual session.

“The pandemic has undermined progress towards the health-related targets in Sustainable Development Goals and laid bare inequities within and between countries,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Sustained recovery will require more than ‘getting back on track’ and reinvesting in existing services and systems. We need a new approach, which means shifting priorities and focusing on the highest-impact interventions.”

“The legacy of colonialism still pervades global health and sanitary policies in Africa and elsewhere,” Simplice Ayangma Bonoho tells me, over Zoom, from Cameroon’s capital Yaoundé. Last Thursday (May 12), his thesis on WHO’s role in developing and implementing sanitary policies in Africa over the last 50 years was awarded the first Forum Suisse de Politique Etrangère (FSPI) Lombard Odier Prize, a joint venture with Geneva University’s Global Studies Institute (GSI). The jury was unanimous in recognizing the value of his research.

In our discussion, Ayangma Bonoho rejects the idea that the last few years have seen a positive paradigm change in the International Organizations’ (IOs) relationships with the Global South. His interview, edited for length and clarity, is below.

Congratulations for the Lombard Odier Award! What led you to write your thesis on the World Health Organization?

International Organizations (IOs) are often opaque, difficult to understand, but they have an impact on people’s daily lives. They have a real effect on people’s lives that is observable on the ground. We see their actions, their interactions with the local populations. It is particularly observable in the field of health, but also in other sectors, such as education and social work more broadly.

You write that you wanted to analyze “the potentially destructuring effects of these policies for the countries of Central Africa, from a political point of view (weakening of States and increased dependence on global health policies), economic (destructuring of the economic fabrics linked to the national pharmaceutical sectors) and socio-cultural (abandonment of local processes of medication and medicalization).” What did you find out?

I studied the implementation of health development policies in Central Africa between 1956 and 2000, to evaluate the importance of health norms and standards of health policies in sub-Saharan African states, and public health actions, like the mass vaccination campaigns. What was the World Health Organization (WHO) […] doing in these countries, in a concrete way, to solve the health problems that the populations were facing? These questions led us to see the evolution of these standards in a very precise way, thanks to on-the-ground studies, archives, etc. And the conclusion, which might not be so surprising for some people, is that Western countries (also former colonial powers) were deeply involved in structuring the health policies and their implementation in those countries. Which led us to conclude that those interventions were imbued with colonial presuppositions.

Has that changed? Your research covers the years 1956 to 2000. We are now 20 years later…

In this kind of historical research, it is important to go to the source of things. In such studies, we look for what we call moments of rupture with past principles, or moments of reinforcement—which we also call ‘survivals’. And it is quite clear, over the span of almost 60 years and up to today, that when it comes to health policies, we don’t really see many moments of rupture, but quite a lot of replications. Yes, there have certainly been notable positive evolutions, but we still see continuous patterns of survival, and so, over time, things have not really changed much.

How do you explain the survival of these post-colonial patterns over so many years and until today?

First, because of the legacy of colonialism. After countries gained independence, the former colonial administrators returned as technical advisers, and pursued the same health and sanitary policies. So, they never really left. The mindset still hasn’t changed. Secondly, these policies represent what other researchers have called “hegemonic transactions,” and that hasn’t changed either. Today, technical advisers operate within WHO and other IOs, and continue to advise those states and their governments. And that perpetuates the logic that prevailed in the past.

How can this be remedied? What is the solution? How do we decolonize the system?

I am advocating for a deinstitutionalization of global public health and sanitary policies on several levels. The first such deinstitutionalization ought to happen at WHO. This is not calling for the abolition of WHO, but for a new way of developing policies; international public health and global health policies. Deinstitutionalization should also be applied at the regional and sub-regional level, so the traditional schemes are not perpetuated. It must go down to the lowest level, in hospitals for instance, but also to individuals themselves, who must understand that health is not something which is given to them, but that it is something about which they have agency; that their health will not be ensured because they go to a particular health institution.

But the organizations responsible for public health are not ready or willing to take such an approach because, obviously, they have no interest in people taking care of their health and not going to the hospitals, which would then suffer negative economic consequences. Once we have managed to implement the real participation of communities in the making of decisions that concern them, we will have made a lot more progress. Today’s fundamental problem is that of the real participation of communities in the formulation and implementation of policies at all levels.

To be honest, I am a bit surprised by what you say about this colonial legacy still enduring so strongly today. We have Africans at the head of WHO, the WTO, UNAIDS, but you seem to be utterly skeptical?

I am. You can take people and put them at the helm of an organization but if they reproduce the same logic, you have not achieved much. It involves more than a simple change of individuals at the head of the structures to ensure change. I think we have just witnessed it with the response to the pandemic. Public health in Africa—and you can say in the Global South—is highly dependent on foreign aid and assistance, mostly distributed through WHO. This is perpetuating the old system we are talking about. It is never truly stated, but the logic of donating vaccines to the South is to allow them to sell them to their populations, in order to buy new doses from the donor countries—rather than facilitating countries in Africa or in the Global South to produce vaccines locally. For instance, that’s what the TRIPS waiver discussion is all about.

Today, there are new organizations active in global health, with different stakeholders, and different kinds of governance. I am thinking about GAVI or the Global Fund. What is your assessment of them?

Tweedledum and Tweedledee!