In a famous speech on foreign debt at the Organization of African Unity meetings in July 1987, Thomas Sankara, President of Burkina Faso (1983-1987), stated:
Debt’s origins come from colonialism’s origins. Those who lend us money are those who had colonized us before. They are those who used to manage our states and economies…Debt is neo-colonialism, in which colonizers transformed themselves into ‘technical assistants’. We should better say ‘technical assassins’…Under its current form, that is imperialism controlled, debt is a cleverly managed reconquest of Africa….
As other Collective members have so effectively argued, global health research and practice are deeply rooted in a colonial history, and neocolonial relationships continue to frame our work. Debt is foundational to these relationships. Depending on who is counting, up to 64 countries in the Global South are in debt distress, and most must spend many times more on debt payments to the Global North, than investments in health or other public social services. Now with the pandemic, a “tsunami of debt” will engulf many of the world’s poorest countries, as Jaime Atienza of Oxfam has stated.
Debt and Austerity
Perhaps most importantly, debt relief from the IMF and G20 only comes in exchange for adherence to market-friendly “conditionalities” that impose austerity, privatization, and deregulation across the Global South, especially sub-Saharan Africa. As a result, the financial flows from the Global South to the North have grown and widened global wealth disparities over the last 40 years of debt crisis and neoliberalism. Foreign debt, and the austerity it helps impose, have capped public financing and crippled public sector health systems and other services in many low- and middle-income countries. Reminiscent of the West Africa Ebola outbreak in 2014, health systems weakened by decades of debt and austerity lie at the center of our epic COVID-19 pandemic failure. With severe public spending limits, foreign aid for health from the North mostly flows to international NGOs for vertical programs rather than local public institutions, further undermining local control and health system building. In Mozambique, almost no American contractors or NGOs (recipients of millions of dollars from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) over the pandemic period) shifted resources toward pandemic-related health systems support – and a full year into the pandemic in 2021 there was still no personal protective equipment available for frontline health system workers.
Debt and the Pandemic
Back in 2020 as the pandemic was unfolding, the IMF and G20 recognized that debt and austerity would severely impede a pandemic response, so they rolled out the Debt Service Suspension Initiative (DSSI) that postponed debt payments around the Global South. But the debt remained and has in fact grown. The DSSI ended in December 2021, and the “Common Framework” was initiated to follow-up. But it has been an abysmal failure – only three countries have made their way through the first steps to apply for relief. The most recent IMF/World Bank meetings in October 2022 were a deep disappointment with no systematic plan to take on the looming tsunami of debt. More austerity now looms across the Global South (as our Collective colleague Alexander Kentikelenis has warned us) that threatens meaningful progress toward UHC, pandemic preparedness, or climate change mitigation. To meet SDG and UHC targets, the WHO tells us, more than 18 million additional health workers are needed by 2030 – an impossible target under current debt forecasts. Many African countries need 10 times as many health workers to meet even the most minimal threshold.
The American Public Health Association (APHA) Resolution on Debt Cancellation
In spite of these bleak prospects, I am delighted to report that just three weeks ago the American Public Health Association (APHA), the largest and most influential public health professional association in the United States, has formally adopted a resolution calling for cancellation of debt among the most debt distressed countries and rejection of austerity. The statement was drafted by a group that includes members of this Collective and was inspired by discussion in a panel on debt cancellation and austerity at the 2021 APHA meetings that featured Collective colleagues including Alexander Kentikelenis, Jomo Kwame Sundaram, and myself (the resolution becomes official in January 2023 and can be shared then). It demands that the IMF and G20 cancel debt among the most debt-distressed nations, provide aggressive debt relief for others, reject austerity, and promote substantial increased financing for public sector health systems and other social services.
The Movement Grows
“Decolonization of global health” must surely include the struggle to cancel debt and reject austerity. It is a global challenge that requires a global movement. But that movement is coalescing, led by End Austerity, debtjustice/UK, JubileeUSA, brettonwoodsproject.org, Eurodad, Latindadd, Afrodad, among hundreds of other civil society groups. In rejecting austerity, Dr. Paulo Ivo Garrido, former Mozambique Minister of Health and participant in our 2021 APHA panel, stated, “Health systems are a country’s mechanism for taking care of its people. If you want to help: strengthen the National Health Service”. Our Collective can hopefully be a venue for sharing ideas and strategies to support this growing movement and respond to Dr. Garrido's call.
