Reimagining global health: From decolonisation to indigenization

ABSTRACT

In the wake of global racial justice and Indigenous sovereignty movements, there have been calls to decolonise global health as an academic discipline and set of policies, programmes, and practices. Identifying these calls for decolonisation of global health as both promising but limited, we argue that global health needs to engage in deeper critical reassessment of its ontological foundations in Western thought and that Indigenous ontologies have an important role to play in deconstructing and reimagining global health. We identify four Western ontological assumptions that are particularly relevant to global health and demonstrate how Indigenous ontologies assist in thinking outside of and beyond these assumptions, offering a path toward a reconstructed Indigenized imagining of global health.

KEYWORDS:

• Indigenization
• decolonisation
• global health
• Indigenous ontologies

Introduction

Global health, in the wake of global racial justice and Indigenous sovereignty movements, has recently taken a decolonising turn. This turn, which follows a much older strand of critical global health and decolonial thought, increasingly recognises that global health is one of the most important global sites in which thought and action must change if the colonial order is to be unmade, reimagined, and remade. However, while not always explicitly acknowledged, colonial ontologies continue to undergird a great deal of putatively global health scholarship, governance structures and practices – including some of these recent efforts towards ‘decolonising’ global health. They do so in ways that foreclose alternate, Indigenous ontologies that have the potential to significantly change how global health is thought and practiced; at times, they also obscure how global health regimes, partly as a result of the colonising assumptions upon which they are premised, can actually produce and perpetuate the very problems they then attempt to solve. Moreover, as a project largely oriented towards deconstruction, a decolonising agenda is incomplete without equally elaborating a reimagined, reconstructive alternative to the current order of things – and this reimagining and reconstruction must begin at the most fundamental ontological levels.

This article therefore develops a two-fold analysis that adds to global health’s decolonising conversation by first identifying some pervasive ontological assumptions in global health that, while often naturalised as universal, objective, value-neutral facts, actually reflect a specifically Western set of conceptions; and then reimagining global health through knowledges held by Indigenous Peoples in what is now known as Canada. We ask, what can global health decolonising / Indigenizing look like from the global North, within a settler colonial state, but through an Indigenous lens?

In asking this question, we acknowledge that re-thinking global health must be part of a dual movement. By itself, a change in thinking is insufficient; as Tuck and Yang (2012) elaborate, decolonisation is not a metaphor. Transformation of global health additionally requires decolonising political action (see, for example, Alfred, 2005; Coulthard, 2014; Gaudry & Lorenz, 2018; Green, 2017; Simpson, 2004). While acknowledging the urgent need for decolonising political action, this article begins from the premise that we begin to change the world by changing how we think about the world. In this respect, we follow Alfred in suggesting that ‘mental and spiritual decolonisation’ is a necessary precursor to structural change because

structural change negotiated in a colonized cultural context will only achieve the further entrenchment of the social and political foundations of injustice, leading to reforms that are mere modifications to the pre-existing structures of domination. A real commitment to justice points us towards both a deeper challenge to the very foundations of the colonial state and culture and the need for an effort to deconstruct and then reimagine the surface and symbolic reflection of the heritage of empire. (Alfred, 2005, p. 180)

To this end, we begin with a dual-level orientation, first situating ourselves as researchers and then taking stock of the global health field’s current discussions about decolonisation. We then illustrate why a deeper engagement with the ontological foundations of global health is needed, by identifying four pervasive ontological assumptions in global health that, while often taken as self-evident and universal, actually reflect particular Western assumptions about the subject (as autonomous individual), the body (as ontologically separable from mind and spirit), and health itself (as a human property, ontologically distinct and separable from the health of ‘nature’, i.e. non-human animals and ecosystems). While this ontological excavation is needed to decolonise thinking in and about global health, it identifies deficiencies but does not propose an alternative; it is only the first, deconstructive step of what must ultimately be a reconstructive project. To support a reimagined and reconstructed approach to global health, alternate ontologies are needed. We contend that Indigenous ontologies, which entail different ways of thinking about global health, have an important role to play in reconstructing a new global health imaginary. Therefore, the second part of this article considers Indigenous ontologies and their implications for global health. We do not claim to present a comprehensive critique of all aspects of global health nor a complete discussion of all Indigenous ontologies and philosophies. Neither do we offer definitive ‘solutions’ to the many problems that exist in global health governance, policies and practice. Rather, our aim is to draw attention to some selective – but important – limitations in current thinking about global health and to some selective – but important – ways in which Indigenous ontologies offer alternatives to this current order.

Orientation: Situating ourselves

We begin our call to rethink global health in a manner that remains unusual in mainstream global health scholarship: by situating ourselves within specific territories and relations with people and land. The authors come to this work with their own unique worldviews and experiences, including working with and alongside Indigenous Peoples throughout the territories claimed by the nation-state of Canada, which have helped to inform the ideas developed in this article. Sean Hillier is a queer Mi’kmaw scholar and registered member of the Qalipu First Nation who grew up economically disadvantaged in a small community in rural Newfoundland. Suzanne Hindmarch is a political scientist and a white settler cis-gender woman raised on Treaty 6 and Métis land (Edmonton, Canada) who now lives and works on the unceded and unsurrendered territory of the Wolastoqiyik and Mi’kmaq Peoples (Fredericton, Canada). Our identities as a settler on unceded Indigenous territories (Hindmarch) and member of an Indigenous Nation (Hillier) matters because ‘ontologies are relative and … the particularities and historicality of Indigenous peoples and nations … give rise to unique characteristics and differences, [including] in stories of origin, in interpretation, and … protocols’ (Stewart-Harawira, 2005, p. 35). Our perspectives, including our own ontological assumptions and understanding of some Indigenous ontologies, have emerged out of specific geographic and political locations, relations, and learning from elders and scholars whose teachings have shaped our own perspectives and intellectual approaches and whom we recognise with gratitude and thanks. Acknowledging our embeddedness in these ongoing, reciprocal, interdependent relations is one example of how Indigenization means doing scholarship differently. From this orientation, we turn to the larger field of global health and recent calls for its decolonisation.

Decolonising global health

An emerging body of literature, inspired in part by student movements in global North medical schools (Hirsch, 2021) recognises the need to decolonise global health. One academic site that has been a focal point for these discussions has been the BMJ Global Health, which published a series of commentaries and editorials on the topic in 2020 and 2021. While we focus specifically on this recent ‘decolonising turn’, it should be noted that medical anthropologists and other critical social scientists have long argued that addressing health inequities and the structural drivers of health and disease requires sustained critical interrogation and transformation of global health and the larger structural forces that shape it (see for example Adams, 2016; Anderson, 2014; Biehl, 2007; Briggs & Mantini-Briggs, 2016; Farmer, 2001). While the current conversation about decolonising global health has generally proceeded on a separate track from this larger body of critical work, deeper engagement with this critical literature, as well as with the Indigenous ontologies that are the focus of our own article, would enrich the more recent calls for decolonising global health.

The most recent decolonising turn emerged in part as a response to the impact of COVID on population health across the globe – an impact that has been markedly inequitable along racial, gender and income lines (Khazanchi et al., 2020; Simba & Ngcobo, 2020). This has invited conversations about structural violence as a determinant of health, and how access to and distribution of healthcare services upholds hegemonic whiteness. Büyüm et al. (2020), for example, note that ‘aside from direct health impacts on marginalised communities, exclusionary colonialist patterns that centre Euro-Western knowledge systems have also shaped the language and response to the pandemic – which, in turn, can have adverse health outcomes’ (p. 1). In response, the authors propose decolonising strategies including recognition of global South success stories in addressing COVID; greater global South leadership; a ‘paradigm shift’ that recognises the impact of interlocking systems of oppression on health; and a ‘knowledge shift’ that teaches global North medical students about colonialism and makes health education materials available in non-English languages.

Some functional aspects of this argument are further developed in commentaries noting the absence of global South voices in calls for decolonisation, proposing pragmatic strategies to increase the representation of African scholars in global health research, publications and organisations (Oti & Ncayiyana, 2021), and a solutions-focused approach to decolonisation that largely calls for reform within existing structures and institutions (Khan et al., 2021). Others have also written about decolonising global health through transnational research partnerships (Lawrence & Hirsch, 2020) and education (Eichbaum et al., 2021; Erondu et al., 2020; Garba et al., 2021).

While presenting a cogent critique of hegemonic whiteness and the dominance of Western knowledge, in moving from critique to action, many of the decolonising strategies proposed focus on small-scale changes within existing structures and institutions. To reiterate the passage from Alfred (2005) cited above, these forms of ‘structural change negotiated in a colonized cultural context’ risk producing ‘reforms that are mere modifications to the pre-existing structures of domination’ (p. 180). In critiques echoing Alfred, Chaudhuri et al. (2021) note that some calls for decolonising global health ‘[appear] to insinuate white supremacist, racist, sexist and capitalist structures of oppressive power’ (p. 3), while Hirsch (2021) questions ‘whether we will achieve structural change while seeking progressive reform and working through channels that were set up within structures that uphold white supremacy’ (p. 189). Moreover, some of these solution-focused approaches have been critiqued for their ‘prescriptive nature’: Chaudhuri et al. (2021), for example, critiquing Khan et al.’s ‘roadmap for decolonisation’, note that ‘its call for “metrics”, “checklists”, and a “map” [are] all tactics that have been and are used by colonisers to assert violence’ (p. 1).

In response to surface-level calls for decolonisation that risk leaving deeper structural inequities and power relations intact, Chaudhuri et al. (2021) call for a ‘radical’ decolonising agenda building on Fanon, Foucault, Mbembe and Freire to critique power relations in global health, ‘open[ing] up further spaces for voice, and shift[ing] away from … Eurocentric cultures’ (p. 4). Similarly, in a call that most closely resembles our own, Affun-Adegbulu and Adegbulu (2020) argue that global health ‘emerged from a Eurocentric imaginary of a world system and a western concept of the human’, and that therefore, decolonisation requires ‘ontological pluralisms in the conceptualization of humanity’ (pp. 1–2). These authors, in emphasising underlying power relations, postcolonial theory, and the need for ontological as well as programme and policy change, implicitly build on the social sciences critical global health literature described above, and Indigenous critiques of Western ontologies (Battiste & Henderson, 2000; Simpson, 2004; Stewart-Harawira, 2005, 2012) that are the starting point for our own analysis.

Overall, what emerges from the recent decolonising turn and the critical global health literature that preceded it is, on the one hand, a welcome recognition of inequitable racial and North–South power relations and their effect on health outcomes. Additionally, in some cases, there is acknowledgement of the relations between power and knowledge production, and the need for transformation at ontological as well as epistemological levels. To date, however, the decolonising turn’s consideration of the ontological foundations of global health has been limited, and where it has been noted, deconstructive calls for ‘unlearning’ and ‘ontological pluralisms’ (Affun-Adegbulu & Adegbulu, 2020) have not been accompanied by reconstructive discussion of alternatives to Western ontologies. Moreover, these critiques have themselves been developed using primarily non-Indigenous frameworks, remaining comfortably within Enlightenment ontologies and philosophical projects. Consequently, in some cases they retain underlying Western assumptions, including anthropocentric approaches to ‘humanity’ and subjectivity.

Notwithstanding these lines of critical inquiry, global health retains deeply held assumptions that, while often taken to be universal and objective truths (sometimes being so taken for granted that they recede, barely visible, into the background of global health scholarship and practice), in fact are the product of Western, primarily European, philosophical traditions. Indigenous ontologies offer a fundamental challenge to these hegemonic assumptions and can therefore extend and deepen a critical re-thinking and Indigenization of global health. They do so both by offering an alternate ontological foundation from which to think, and by offering a reconstructive path forward.

Excavating the assumptions of Western global health knowledge

We now turn to four assumptions that pervade Western philosophical traditions and that have been instantiated in global health thought, organisation, and practice: that individuals exist as autonomous subjects; that mind, spirit, and body are distinct; that the human and natural worlds can be meaningfully separated; and that in the hierarchy of living beings, humanity is at the top. These assumptions have been foundational to global health discourse and are now deeply embedded in global health programmes and practice. We are not the first to develop these critiques of Western philosophies and their ontological foundations; indeed, we focus on these four assumptions because they feature so prominently in Indigenous and postcolonial critiques of Western knowledge systems (e.g. Battiste & Henderson, 2000; Hall, 1992; Kimmerer, 2013; Tuhiwai Smith, 1999), even as they acknowledge the diversity and divisions within ‘Western’ thought (Appiah, 1992, pp. 86–93). Here, we briefly outline how these four assumptions manifest in, and why they are problematic in, global health – and why they must therefore be addressed, via Indigenization, in global health’s decolonising turn.

The autonomous, individual subject

In the Anglo-European liberalism of Locke, Mill and their intellectual inheritors, the rights-bearing individual is assumed to be the most basic political unit. Ontologically, the individual is assumed to exist as a subject prior to social relations or processes of identification with and recognition by larger social groups. This ontological individualism is also evident in global health, notwithstanding the ostensible population-level focus of social determinants of health analyses and interventions. Certainly, a recognition that many drivers of health and disease operate socially rather than individually then implies that improving population health requires social and structural interventions. But when it comes to practice, to specific programmes and interventions, the answer to the question ‘how can we improve the health of X population’ is often behavioural interventions that are targeted at individual bodies and behaviours, and predicated on the assumption that individuals are autonomous, rational actors capable of making ‘healthy’ choices. More fundamentally, interventions aimed at changing individual behaviours and choices (e.g. to stop smoking, to eat vegetables, or to use bednets and clean-burning cookstoves), even if they include taxes, subsidies, or other social-structural policy levers, still treat health as a property that ultimately inheres in the individual. Each person’s good or poor health is, in the final measure, assumed to be determined by their own individual dietary choices, serostatus, weight, and so forth, and if a sufficient number of individuals within a given population meet the indicators that designate them as healthy, the population as a whole is then deemed healthy. In other words, the assumption is that population health results from an aggregation of discrete, individual behaviours and choices, which can each be studied, targeted, modified, and disciplined in isolation. While this is an example of methodological (not ontological) individualism, as a methodology, it can only become ‘thinkable’ within an ontological frame of reference that treats each person as an ontologically distinct, autonomous subject.

Cartesian dualism

Arising from the ontological assumption of autonomous, individual subjects is the Cartesian division of mind and body (matter). As Stewart-Harawira (2005) notes, in spite of intellectual challengers within Western thought, ‘the Cartesian division of matter and mind … provided the rationale for scientific hypotheses that atomised matter into isolated fragments’ (p. 45). In global health, the resulting assumption that the (health of) mind, body, and spirit are separate and separable is evident at a macro level in the way that health services and medical disciplines are organised, and in the way that they treat the body (physical health) and mind (mental health) as discrete and ontologically separable. Psychology and psychiatry treat the mind; specialties such as cardiology, dentistry, oncology, obstetrics, and gynaecology treat different parts of the body, and different diseases. Spiritual concerns are placed entirely outside of the realm of health, belonging properly to the field and institutions of religion. In global health policy and practice, the fragmentation of body and mind is also reflected in ‘disease silos’, including disease-specific organisations, strategies, and funds. This approach to global health challenges could only have emerged from a worldview in which mind, body and spirit are already ontologically assumed to be distinct parts of the ‘self’, and in which it is already accepted that each part can be studied, understood, and acted upon in isolation.

Human-nature binary

As Battiste and Henderson (2000) and Stewart-Harawira (2005, 2012) have explored at length, the Cartesian severing of mind and matter also places the rational human subject outside of nature. Moreover, as Affun-Adegbulu and Adegbulu (2020) note, it places both Man and white men into the category of rational and fully human subjects, while relegating women and racialised peoples of all genders to the category of less than fully rational, closer to nature and thus less than fully human. The racialised hierarchy of human subjects enabled by this human-nature binary is particularly relevant for Indigenous Peoples: as Campbell (1992) explains, the ontological relegation of the ‘Indian other’ to the realm of savage, uncivilised nature in the work of Hobbes and other Enlightenment philosophers played a key role in the material subjugation of Indigenous Peoples through settler colonial projects. For perspectives that assume a human-nature binary, Cartesian man, standing apart from (i.e. ontologically separate from) ‘nature,’ can then achieve objective knowledge of and mastery over nature through reason and scientific method.

The assumption of a fundamental separation between human and natural worlds remains evident in the field of global health, first, in the functional and disciplinary separation of human medicine from animal medicine, and of both of these from botany, biology, and other disciplines that study non-human ecosystems. Notwithstanding recent attention to environmental health and linkages between climate change and health, for the most part global health has been resolutely anthropocentric. Recent calls for decolonising global health, for example, demand critical engagement with political and social systems including ‘white supremacy, racism, sexism and capitalism’ (Chaudhuri et al., 2021, p. 1) but not the connection of these systems to extractivism and other systemic environmental exploitation of human and more-than-human life; calls to decolonise medical school curricula demand that students be taught about colonialism and racism, but not about the interconnectedness of animal, planetary, and human health (Garba et al., 2021). As we discuss below, even in recent treatments of One Health, ‘the environment’ is still in many cases treated as something that can influence, but is ontologically distinct from, human health.

Anthropocentrism

Kimmerer (2013) reminds us that the human-nature binary is simultaneously a hierarchy: ‘[i]n the Western tradition there is a recognised hierarchy of beings, with, of course, the human being on top’ (p. 9). This reflects the Western ideal that humans are and should be the most important entity on earth, and thus our health and survival are of the greatest importance. As already noted, this anthropocentrism endures in many calls to decolonise the ontological underpinnings of global health; Affun-Adegbulu and Adegbulu (2020), for example, critique hierarchies within humanity, but not the anthropocentric privileging of humanity over the rest of the more-than-human world.

We note that a recent exception to global health’s anthropocentrism is the growing attention to One Health, which conceives of human, animal, and ecosystem health as interdependent (Gruetzmacher et al., 2021). One Health offers a conceptualisation of health that embeds human health in larger ecologies and ecosystems, in ways that may in principle be complementary to Indigenous perspectives on health and human and more-than-human relations. To date, however, One Health interventions have not deeply engaged with Indigenous knowledges or ontologies, instead retaining Western methods and approaches to disease control (Hillier et al., 2021). One Health has also had limited traction in global health governance practice, in part because most global health organisations and mechanisms entail disease and disciplinary silos that resist such holistic approaches to health (Lee & Brumme, 2013). Additionally, the relationship between people and nature in One Health approaches is still sometimes conceived of as oppositional and entailing a hierarchy, with zoonotic disease, for example, positioned as separate from and threatening to human health, and treated as a hostile external force. This conception of animals and ‘nature’ as a source of threats to human health still privileges human health and well-being, with One Health becoming a means to an anthropocentric end.

Indigenous ontologies: Towards Indigenizing global health

In contrast to Western conceptions of health as essentially human, biomedical, and individual, Indigenous ontologies offer a different starting point from which to theorise global health. In emphasising the ontological distinctions between Western and Indigenous approaches, our claim is not that these ontologies are diametrically opposed. Rather, we suggest that Indigenous ontologies, rooted in holism and relationality (Stewart-Harawira, 2005), offer perspectives that are better understood as more than, not entirely different from Western ones. For Battiste and Henderson (2000), Indigenous knowledges are ‘scientific in the sense that [they are] empirical, experimental and systematic’ (p. 44), but depart from Western scientism because they are localised, grounded in millennia of understandings of animal, plant, and human relations in specific territories rather than oriented towards developing universal laws. Similarly, Kimmerer (2013) explains that Indigenous knowledges are not anti-science but ‘science-plus’, a process of culturally-grounded interpretation of the more-than-human world.

Indigenous ontologies and knowledges are diverse and complex, resisting attempts at categorisation and generalisation. Battiste and Henderson (2000) identify several challenges in defining Indigenous knowledges, including that they are contextual to particular ecosystems and Indigenous Peoples, and are encoded in song, dance, stories, ceremony, and daily practices, making them often difficult to explain in writing. Furthermore, language, land, and worldviews are interconnected, as ‘most Aboriginal worldviews and languages are formulated by experiencing an ecosystem … Aboriginal worldviews are empirical relationships with local ecosystems, and Aboriginal languages are an expression of these relationships’ (Henderson, 2000, p. 259); there are inherent limitations when discussing Indigenous ontologies in English and out of context.

Nevertheless, there is widespread (though not universal) agreement that ‘[d]espite their diversity, identifiable among Indigenous ontologies and epistemologies are core sets of principles, beliefs [and] ways of knowing’ (Stewart-Harawira, 2012, p. 78), even if these take different forms when articulated within particular Indigenous communities. Indigenous ontologies, for Stewart-Harawira (2012), are ‘[p]redicated upon relationality and reciprocity … [and] deep interconnectedness of being’ (p. 78). Especially, this relationality and interconnectedness is derived from and expressed through relationships to the land, and through kinship networks that span space and time (Battiste & Henderson, 2000). Together, relationality and interconnectedness produce an ontology of holism in which the self is not ontologically prior to, but rather comes into being through, relations. This ontology eschews binary oppositions such as mind/body and man/nature, as well as anthropocentric hierarchies (Kimmerer, 2013). In sum, Indigenous ontologies are holistic, situated, encompass human and nonhuman lifeworlds, and are predicated on ‘the inseparable nature of the relationship between the world of matter and the world of the spirit’ (Stewart-Harawira, 2005, pp. 40–42, 49–50).

These temporal and spatial relations and interconnections are expressed, for example, in the Seven Grandfather Teachings, which form a foundation for the way of life for many Indigenous Peoples in the territories glossed as ‘North America’, notably the Ojibwe / Anishinaabe Peoples, but others have similar teachings. The teachings of Indigenous cultures encompass the morals, values, structures, ceremonial practices, and spiritual beliefs of the group; these teachings ensure the survival of Indigenous Peoples. The Seven Grandfather Teachings encompass the following principles: Love, Respect, Bravery, Truth, Honesty, Humility, and Wisdom (Benton Banai, 1988). Each of the teachings must be used in conjunction with one another: one cannot be Wise without also practicing Love, Respect, Bravery, Honesty, Humility, and Truth. These foundational teachings, for the Indigenous Peoples who follow them, foster both a spiritual relation (alignment with the Creator), and human relations with and responsibility to everything around us: the earth, water, animals, and one another – a holistic ecosystem. Each teaching honours one of the basic qualities that are necessary for a full and healthy life and is represented by an animal to show the connection between the animal world, the environment, and people.

Through these teachings, we can better understand an Indigenous approach to health: the Medicine Wheel or Four Directions that encodes the worldviews of several Indigenous Peoples in the territories claimed by Canada and the United States.¹ The Medicine Wheel is (for some Indigenous Nations) informed by the Seven Grandfather Teachings and is visually depicted as a circle divided into quadrants, with each quadrant representing one of the Four Directions. The Four Directions represent and express relations between sets of four, including the four geographic directions (north, south, east, west); four seasons; four life stages; four elements; and importantly, four aspects of being (mental, physical, emotional, spiritual). Animals and plant-based medicines, local to specific Indigenous ecosystems and Nations, also form part of the Medicine Wheel teachings. The Medicine Wheel thus represents, in a single circle, aspects of oneself (the four aspects of being), but also how these aspects of self are connected across time and kinship networks to one’s ancestors and descendants, and across space to elements of the natural world (mother earth). ‘The teachings of the Medicine Wheel are completely holistic: you cannot see the elements as separate parts but must seek to understand the relationship between all parts’ (Jobin Vandervelde, 2010, p. 157) and to achieve balance and harmony in these relations. What is expressed here is an ontology that is holistic, situated, encompasses human and nonhuman lifeworlds, and that expresses ‘the inseparable nature of the relationship between the world of matter and the world of the spirit’ (Stewart-Harawira, 2005, pp. 40–42, 49–50). It is the goal of all peoples to be healthy, and to be healthy, we must all be in balance according to the Medicine Wheel. This balance must be found not only within oneself; rather, collectivities and communities must also be in balance (King et al., 2009). Similarly, human communities cannot be in balance and healthy if the earth and water are unhealthy, as this will lead to the animals being unhealthy, all of which impacts our collective health and balance. In this ontology, there is no hierarchy among humans, animals, or the environments we live in; instead, we must be in harmony with one another through balanced, reciprocal relations, and we, as humans, must act as stewards of the world in which we live.

What, then, would it mean to Indigenize global health: to reimagine and reconstruct it through Indigenous ontologies? For those trained in Western philosophical and disciplinary traditions this is a difficult, even uncomfortable question. Mainstream public health practitioners, policy-makers, and health researchers are not accustomed to discussing ‘the spirit’, nor of thinking of the earth as a living entity and of its more-than-human lifeforms as our relatives. But this is precisely the point: the ‘we’ that has shaped global health as a concept and practice has for the most part been non-Indigenous, and Indigenous ontologies and philosophies do not fit neatly within dominant global health systems, structures, categories or forms of governance – even many ostensibly ‘decolonising’ ones. Indigenization, while not requiring a simple inversion of the ‘West and the rest’ hierarchy in which all that is Indigenous becomes good and all that is Western becomes bad, requires unsettling received Western knowledge and ways of knowing.

First, Indigenous understandings of the subject, self, and body imply a holistic understanding of ‘health’ that, even more than One Health and the Alma Ata definition of health as ‘a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity’ (UNICEF & WHO, 1978), envision health as integration and balance of mental, physical, emotional, and spiritual well-being. This is also a grounded understanding of health as situated in and dependent on particular geographic and ecological systems; and of health as not a static condition, but an ongoing, continuous set of relationships, including relations with the land. ‘Health’ cannot be objectively defined through a ‘view from nowhere’ but must be understood with reference to local ecosystems, plants, and animals, as well as local histories. Additionally, in the Medicine Wheel, the health of each component/aspect is dependent upon the health of all. In other words, health is a collective and community property, not an individual one. In this imaginary, it is exceedingly difficult to talk or think about the health of an individual in isolation and without reference to social and ecological context, since that individual’s health is produced by and through relationships with people and place.

An Indigenized approach to global health then implies, among other things, a holistic and strengths-based focus on health and well-being (rather than disease-specific modes of organisation) and on collective (not just individual) health. Again, we can look to Indigenous Peoples in the territory claimed by Canada to provide one example of how this way of thinking about health could be ethically and meaningfully taken up. Two-Eyed Seeing or Etuaptmumk (‘I see both sides’) was first coined by Mi’kmaq Elders Albert and Murdena Marshall ‘as a means to bridge Western science and Indigenous knowledge’ (Martin, 2012, p. 22) by ‘bring[ing] together our different ways of knowing to motivate people, Aboriginal and non-Aboriginal alike’ (Bartlett, Marshall, Marshall & Iwana as quoted in Martin, 2012, p. 21). It has been used to foster the seeing or understanding of ideas, concepts, and arguments from both Western and Indigenous perspectives: Indigenous knowledges and Western sciences can interact in a dynamic way to support relational knowing, being, and doing and allow for a more diversified understanding of the world.² Importantly, while sometimes treated as a methodology, Two-Eyed Seeing derives from – and may best be understood as – a relational, holistic Indigenous ontology (Roher et al., 2021) that eschews binaries, dichotomies, and the assumed primacy of Western knowledge and of the human over the more-than-human world (Martin, 2012; Roher et al., 2021).

Indigenizing global health also suggests a different conception of ‘the global’. Rather than implying de-territorialised flows above and across states (Anderson, 2014), from an Indigenous standpoint ‘global’ instead suggests a network of relationships that span time as well as space (Stewart-Harawira, 2005), and that include relationships in and with what is glossed in non-Indigenous philosophies as ‘the environment’. Indigenous ontologies, with non-linear conceptions of time in which ancestors and descendants are always already present, offer a different way to historicise the relations that comprise ‘the global’. They also, because they are grounded in an ontology of interconnectedness characterised by specific relationships to ecosystems and land, require that we contextualise these global relationships firmly in ‘the local’. Indigenizing global health may then enable the ‘historical and cultural analysis’ that Anderson (2014, p. 377) worries has been lost in the turn to the global. Doing so from an explicitly Indigenous rather than generally postcolonial vantage point may address the concern expressed by some Indigenous scholars that postcolonial theories themselves do not always incorporate Indigenous ontologies or enable recognition that Indigenous Peoples in settler colonial states are in no way ‘post’ colonial. Indigenous ontologies also do not conceive ‘the human’ world as autonomous or separable from nature; Indigenizing global health then requires a move away from anthropocentrism, meaning that critical global health cannot only ‘follow people’ and ‘human consequences’ (Adams, 2016, p. 194).

Finally, many Indigenous ontologies that conceive of relations using a circle or spiral, such as the Medicine Wheel, understand being as an ongoing process of balancing; the life of people, communities and ecosystems is understood as iterative and regenerative, not as a teleological path of linear progress. This, too, has implications for how we think about global health, especially the points at which it intersects with the discourses and practices of development. It is certainly empirically true that many people in the world lack access to clean water, essential medicines, and other health-giving materials and technologies, and many of these people are Indigenous. But what would it mean, for example, for us to approach health and development as redistributive projects seeking to achieve balance (as articulated in Indigenous ontologies), rather than as knowledge and technology transfers seeking to bring progress to ‘underdeveloped’ people and communities? Simply ‘finding balance’ within existing political and economic configurations is insufficient, but what would it mean for us to orient thinking and political organising in global health around the concept of balance rather than progress? Importantly, Kimmerer (2013) emphasises that balance does not mean stasis; rather, it is a ‘moving target’ (p. 94) entailing ongoing, reciprocal relations between land, plants, animals, and people.

Conclusion: From ontology to politics

An Indigenous re-thinking of global health, while beginning at the level of the ontological, then produces political imperatives. These include the need for structural change encompassing ecological and environmental concerns and for recognition of Indigenous forms of sovereign territoriality. Indigenizing health is not just about making the concept more holistic by incorporating Indigenous teachings but also about a political acknowledgement that for Indigenous Peoples in settler colonial states, health, once understood as grounded in relationships with and stewardship of the land, then requires recognition of Indigenous claims to that land (which entails something more and different than legal recognition of land ‘ownership’ in the Western sense; e.g. see Pasternak, 2017). Consideration of the political action required to achieve Indigenization in and beyond global health is beyond the scope of this article. Briefly, though, Indigenous environmental justice movements such as those recently articulated in Indigenous anti-fracking and anti-pipeline protests in Canada and the United States seem to offer new modes of health politics from below. These movements anchor ‘global’ health in local contexts, while connecting ‘local’ health problems to larger global economic and political structures, and articulating a mutually constitutive relationship between human and more-than-human health and ecologies. For example, in the Dakota pipeline mobilisation, Indigenous activists articulated a holistic understanding of health in which the health of the land and water itself was understood to be reflective and constitutive of the community’s health (Estes & Dhillon, 2019). Similarly, Inuit across the Circumpolar North are fighting for stewardship rights related to the ongoing seal hunt and international bans on seal furs, which have decimated local economies and resulted in significant health challenges. Holistic health for Inuit means being stewards of the land and animals, ensuring balanced relations among human and more-than-human lifeforms. However, through international bans, the resulting imbalances, including the overpopulation of seals, have meant reduced fish stocks and the spread of zoonotic diseases – all of which negatively impact local human populations (Rogers & Scobie, 2015) and their more-than-human relations. These modes of health politics from below entail empirical recognition that poor health outcomes are ultimately driven by ongoing coloniality and racism. But they are also predicated on Indigenous ontologies of relationism and holism, in which the human self is not self-contained but embedded in larger non-hierarchical, interdependent networks of reciprocal obligation that encompass more-than-human lifeforms.

We are at a political and disciplinary moment characterised by growing recognition of ecological and politico-social crises arising largely from Western modes of thinking about and then interacting with/in the world, including through destructive colonial projects. Global health continues to grapple with the deeply inequitable health impacts of these crises, as well as the ways that global health as a discipline has been and continues to be implicated in perpetuating Western universalism (Affun-Adegbulu & Adegbulu, 2020), structural violence (Farmer, 2003) and white supremacy (Abimbola & Pai, 2020). Indigenous ontologies offer multiple means of thinking our way outside of some of the inherited assumptions from Western philosophical traditions that pervade global health and of thinking critically and creatively about how to respond to these challenges.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 For one example of Anishinaabe Medicine Wheel teachings, see Absolon (2010). The Maori use the visual representation of the spiral to express similar spatial and temporal relations.

2 Similarly, an Inuit approach to knowledge creation, aajiiqatigiingniq (Ferrazzi et al., 2019) is used to reach consensus while promoting respectful, open, unhurried discussion to support collective decision-making.