Colonisation and its aftermath: reimagining global surgery

Abstract

Coloniality in global health manifests as systemic inequalities, not based on merit, that benefit one group at the expense of another. Global surgery seeks to advance equity by inserting surgery into the global health agenda; however, it inherits the biases in global health. As a diverse group of global surgery practitioners, we aimed to examine inequities in global surgery. Using a structured, iterative, group Delphi consensus-building process drawing on the literature and our lived experiences, we identified five categories of non-merit inequalities in global surgery. These include Western epistemology, geographies of inequity, unequal participation, resource extraction, and asymmetric power and control. We observed that global surgery is dominated by Western biomedicine, characterised by the lack of interprofessional and interspecialty collaboration, incorporation of Indigenous medical systems, and social, cultural, and environmental contexts. Global surgery is Western-centric and exclusive, with a unidirectional flow of personnel from the Global North to the Global South. There is unequal participation by location (Global South), gender (female), specialty (obstetrics and anaesthesia) and profession (‘non-specialists’, non-clinicians, patients and communities). Benefits, such as funding, authorship and education, mostly flow towards the Global North. Institutions in the Global North have disproportionate control over priority setting, knowledge production, funding and standards creation. This naturalises inequities and masks upstream resource extraction. Guided by these five categories, we concluded that shifting global surgery towards equity entails building inclusive, pluralist, polycentric models of surgical care by providers who represent the community, with resource controlled and governance driven by communities in each setting.

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“…Focus has now turned to locally championed interventions. 13 Inequities of global surgery were examined by Qin et al 14 They identified Western epistemology (established from colonialism), unequal participation, and geographic inequity as some of the barriers to inclusive global surgery. 14 The World Bank classifies South Africa as an upper-middleincome country.…”

“…13 Inequities of global surgery were examined by Qin et al 14 They identified Western epistemology (established from colonialism), unequal participation, and geographic inequity as some of the barriers to inclusive global surgery. 14 The World Bank classifies South Africa as an upper-middleincome country. 15 However, the country has one of the highest inequality rates described globally due to a large percentage of the population living below the upper-middle-income country poverty line.…”