A few personal thoughts on what we mean by inclusive societies, steps needed to get there, and the danger of focusing on our comfort zones and process rather than on impact.
A few days into my new role, I am writing this blog from Mexico City, where I am attending an international conference on eye health. I have a steep learning curve on several issues, yet many conversations are familiar: How can we reach the most marginalized populations? What is needed for integrated systems and more sustainable approaches? What do we do in the face of polycrises? And ultimately: What steps are required for an inclusive society?
Agreeing on a vision for an inclusive society sounds easy. Yet looking at the political environment in many countries, in all regions of the world, we can see that polarised views affect also this issue. Does inclusivity require conforming to a particular norm (eg. eroding LGTBQI+ rights, women’s rights, or rights of nationhood)? As we advocate for change in 2024 and beyond, it’s important that we acknowledge these increasing divides in world views, even on issues that we have seen progress on over the past decades, such as human rights and disability rights.
Agreeing on steps toward a more inclusive society is even more difficult. Should NGOs continue to play a central role in advocacy and needs-based service provision, or should this be the responsibility of and funded by the state? Should our work focus on medical needs and health interventions, or should we also work on broader societal environments (inclusive workplaces, urban spaces, the digital world)? Is being “on the agenda”, noted “in a resolution”, or being “invited to the table” sufficient to spark change, or do we need to more transformatively address systems and societal norms?
As we face rollbacks in rights – and very concretely see cuts in funding that over the past decades enabled more inclusive societies – we need to be ambitious, louder, and acknowledge new political shifts and realities. We need to move beyond silos and build value and rights-based coalitions. And ultimately: we need to be much more self-critical and evaluate each step we take, asking ourselves whether we are really progressing not just on process, but real impact.
I grew up in Vienna/Austria in an international community where our differences as children were celebrated as a richness. I was oblivious to the different colours of our skins, our religions, or associations people had with our foreign names as being “problems”.
I’ve been a foreigner in the places I have lived for the large majority of my life. I know what it feels like to feel slightly out of place, but usually I’ve blamed it on the place and the (uniform) people in it, not myself. My “home” and place of comfort is the international community I was brought up in.
But I know I had and continue to have it easy. I’m a Northern European white person who has lived in Europe nearly all of my life, educated at elite universities. I’ve never stuck out, and have always spoken the languages of the countries I have lived in, and the lingo of communities I have worked in. I’ve only later heard of names my non-white friends were called – also as small children – and the cultural, ethnical or gender stigmatisation and discrimination they have faced and continue to face.
Global health and development, privileged
I have been thinking about and working on diversity in the global health and development sector for quite a few years. I openly admit that I can’t identify with some of the feelings of stigmatisation and discrimination people face, because I don’t share their experiences, sense of community, nor history. But I can feel empathy, and agree that their anger, disappointment and call for change is needed and justified.
I share their sense that something is so utterly wrong if a meeting room is full of white, old men, with high salaries, all perfectly fluent in English. And when the same people sit on every single board. Or if young people, people of colour, women, civil society advocates, or foreigners are only present in functions such as secretaries, interns, or cleaning ladies, or to listen to “wisdoms”, or to observe decisions or ensure a diversity box is being ticked.
I recently watched a video discussion between four black women in leadership roles in global health (Black Voices in Global Health: Equity is Personal), convened by Global Health Council’s fabulous Executive Director, Loyce Pace. How does it feel to be the only black person in the room, have to listen to a 27-year old white consultant arrogantly boss around African Ministers, or what does it feel like to be responsible for creating space for others who expect this? These aren’t abstract questions, these are personal experiences. And they reflect on our entire development community.
White saviour complex, dead aid
In international development, there has been some discussion on what is termed white saviour complex. White people, usually privileged and living in the Global North (like myself), find fulfilment and success working in international development, motivated by something along the lines of “saving poor (mainly black) people”.
The “complex” part is that the motivation is not seeing someone else succeed or overcome their challenges independently, but feeling as if only one’s own actions have meaning and power – benevolent power.
These discussions were a decade ago raised in a slightly different form by Dambisa Moyo in 2010 in Dead Aid, and William Easterly in 2006 in The White Man’s Burden. Moyo and Easterly went a step further, not just questioning who is providing aid and setting the agenda, but questioning the concept of aid itself.
Working in international development for 15 years, as a white person from the Global North, I continue to struggle with these questions. And I continue to ask whether I am part of the solution, or part of the problem – because of who am I and where I come from, but also because I am a part of this sector.
Me and this group first!
I’ve often felt that narrowing the inclusion debates to one population group alone beats the purpose. As a woman in gender discussions, I’ve felt slightly uncomfortable with the call that “now it’s time for women to lead” (because they’ve been denied this right for centuries). Why just women, why not people of colour? Why not young people? Why not those without elite degrees? Why not people who have grown up in the countries that we are trying to support through our work?
I recently saw a picture of three women leaders. The criticism was “diversity fail”. Why? Because they were all white. And yes, I agreed when I reflected on this. A picture I would have first applauded as a success.
I have raised the discomfort I have with these diversity issues before, because privileges and discrimination can co-exist. Yes, I have invited onto panels because I was a young woman working in civil society – but I am also white, living in the Global North, and educated at elite universities. Am I therefore best placed to represent and speak on behalf of “the rest of the world”? Is it more important that I am a woman, above, for example, having a perspective and experiences from the South?
I’ve raised these concerns with colleagues and friends, and some have replied that our functions should be to tell other people’s stories, raise their challenges, or whenever possible, give or share our platform with others. In these instances, I think of those speakers who have physically stepped off their panel to give someone else their seat. Or used their slot to call out their own privilege, to make clear to the audience that next time, they should expect the organisers to invite the person affected, not the known suspects who seem to tour conferences as a profession. And I’ve wondered: would this sector be a better place if people like myself would leave?
What next?
Just as in global health, where our community seems to move from disease to disease, in the diversity discussion we seem to be moving from one population that needs to be included to another. Women! Youth! Global South! Black people!
We have campaigns, movements, expect declarations and commitments. Data. Reports. Accountability.
Perhaps this is the way change happens? In bursts, when there is attention to an issue? When it can sustain momentum, even when the next three issues explode and everyone suddenly pivots in that direction? Or when the next explosion happens, and everyone realises we have moved three steps back or only an inch forward since the last crisis, because everyone’s attention drifted elsewhere? Was there ever really any interest for change in the first place, or just pressure to say something, commit to something?
There must be some better way to advance the diversity and inclusion agenda. In a way that looks at more diverse facets and variables, instead of fixating on one aspect. Working together to benefit everyone, instead of pitting one group above all others and flooding that group with empathy in that (short) moment (with no real or sustained action that follows).
I am in no way belittling the discrimination many people or groups have faced or continue to face. I am also not questioning activists, advocates or movements that try to create change. Very little positive change would probably have come about without such focused campaigning and advocacy.
But I am questioning whether we could not go about this change making differently. Just as we’d finally seemed to come to agreement in global health that the disease-after-disease-after-disease approach won’t get us to the impact level we need to achieve (and then came Covid19…). Can we not find a way to agree that women-youth-Global South-blacks-add-your-group is not the way to get to meaningful and real diversity and inclusion, fast enough?
My question and reflections will most likely anger and alienate every person who associates strongly with one group, or issue. Perhaps that means most people. But for people like me, who’d like to see more diversity – full stop – these are hopefully questions that will help trigger more reflection and action more broadly.
In practice, one place where we could start is governance, and board diversity criteria, also for specific board role functions. Not just looking at women. Or high-vs-low income countries. But all facets of diversity.
Global health is full of grand statements. “Global health is political.” “Health is an investment, not a cost.” “Health is a human right.” “Health coverage is a social contract.” “Health is a determinant of wealth.” Or as the first line of the SDG health targets reads: “health…is essential to sustainable development.”
As global health advocates and specialists, we are used to seeing and also using these statements to explain or justify the importance and links of global health to social, economic and political aspects of life.
In our global health-centric world, global health is linked to everything. But what is it – and what are we as global health specialists – responsible for?
For each of the statements above, global health provides a series of experts, as well as organisations, institutes or platforms with mandates to match the scope. There are economic or financial global health experts and organisations, normative ones, and an increasing multitude of global health experts that specialise e.g. in law, governance, gender, or human rights.
Global health of the few?
However, during the Covid pandemic, we have also seen many global health specialists draw tighter boundaries around our field – and with this, our responsibility as people working in global health. “Political decision-makers are responsible for making and implementing policy, we provide scientific guidance.” “Our role in global health is to propose policies based on best practices and an evolving scientific body of evidence.” Covid19 advisory bodies and the media have narrowed and medicalised this focus further. Political scientists, economists, civil society or gender specialists focusing on global health have been relegated to the sidelines, or have simply been left out. Do they bear responsibility if they have not been included?
Global health before (and after?) Covid
Contrary to what we are seeing during the Covid19 pandemic, global health has evolved and expanded greatly over decades. A quick search on Wikipedia outlines the scope of global health as “health in the international context” that includes:
“Medicine describes the pathology of diseases and promotes prevention, diagnosis, and treatment.
Public health emphasizes the health of populations.
Epidemiology helps identify risk factors and causes of health problems.
Demography provides data for policy decisions.
Economics emphasizes the cost-effectiveness and cost-benefit approaches for the optimal allocation of health resources.
Other social sciences such as sociology, development studies, psychology, anthropology, cultural studies, law and human rights can help understand the determinants of health in societies.”
(Interestingly, political sciences (including governance) are not yet included in this list, but many of us would argue they are intrinsic to global health, as a determinant, context, and as an agent.)
What is interesting to see during Covid is how many advocates, experts and organisations are trying to use Covid as a case to justify why a broader scope and responsibility is needed (or at least organisational mandates and financing to go with it). On the other hand, much in the economic, political and social spheres and context is taken as a given – as something external to global health. And often, when it comes to responsibility for impact, this lies outside of global health, according to those working in global health. What is coming through is something along the lines of “We’re just the experts, others should be the doers and take responsibility.” We’re also hearing very few voices and seeing the same faces, fed to us again and again by the media and various webinar panels or op-eds, in these discussions.
Legal responsibilities vs practical power
Legally, we operate in a global system of nation-states, where governments are responsible for the health and security of their populations. But as we know and acknowledge in practice, many private sector firms and philanthropies to date already have more power and funding than several states combined. And specialised knowledge and expertise often lies with individual experts or research institutions or firms, as Covid has clearly shown. There’s also the question of who is responsible for global goods or services that are needed not only for one nation-state and its population, but for all people, including those that may be e.g. stateless, or excluded actively due to discrimination, or indirectly due to lack of or different prioritisation of resources.
Responsibility of leaders, thought leaders and advocates
Kristof Decoster in his recent and excellent blog asks this question in a different way by noting his disappointment that global health leaders, including thought leaders have “wasted” the Corona moment, by not focusing on the needs to reform the financial, tax or economic sectors. Kristof’s position, if I may interpret and paraphrase, is that we are all responsible for transformational change if we claim to want to have impact (save lives, improve health, ensure sustainability, etc.).
Kristof explicitly lists some thought leaders in global health, who have good access to decision-makers and could think and advocate bigger. But I think this question just as well applies to each and every one of us working in global health, no matter whether we are epidemiologists, economists, political scientists, advocates or communicators; and no matter whether we focus only on the local, national, regional or global. Are we thinking, collaborating and acting big enough to have real, sustainable and global impact?
Responsibility for what?
One challenge that we face is that global health is highly fragmented and specialised, but on the other hand has boundaries that blur into hugely complex areas such as local to global politics, economics, and security. It is much easier to feel responsible for the area you have specialised in, and many people feel uncomfortable addressing issues that they do not have a degree in, or credibility or experience on. Is a medically trained epidemiologist suddenly supposed to be knowledgeable about tax and gender policies, or local political governance? Vice versa, is a political advocate suddenly supposed to have opinions and advice on alternative treatments? Is someone working in public health at the community level in Latin America supposed to have expertise on transnational policy-making?
For me, the answer is simple. One person or organisation does not have to have expertise on everything, nor is it realistic to expect this. Such a person would have to be a genius with the depth and breadth required; and one organisation would have to be so large, so complex, so diverse, and be able to recruit the best expertise from every area and region, without becoming bureaucratic, stagnant or monopolistic. But each and every one of us has the responsibility to collaborate and to incorporate knowledge and best practices from other individuals, organisations, fields, political levels, and countries in an inclusive way. We all have the responsibility to think about factors that influence our impact, no matter how specialised our focus or field is, and if that requires learning more, reaching out to more people, and thinking big and out of our comfort zones and specialisation, that’s what we need to do.
A turn inwards
One common criticism during the Covid crisis has been that governments have turned inwards. But perhaps we – who are working in global health – should be asking ourselves this same question? Are we in global health turning inwards, claiming responsibility only for medicalised approaches and a scientific focus, but not for policy, financing, global collaboration, anti-discrimination, or public health communication? Are we collaborating sufficiently with other sectors? Are we learning from others? Are we inclusive of diverse perspectives? Are we taking advice from others’ best practices, or only expecting others to take on our evidence and guidance?
Responsibility is a heavy word, especially when lives – millions of lives – are at stake. But if we in global health shy away and disengage from collaborating and thinking big and truly inclusive now, we’ll have limited impact, far beyond the Covid19 response.
When Ngozi Erondu, Madhu Pai and I wrote co-wrote an article on exclusion and privilege in global health, published a day after the death of George Floyd, I expected quite some push-back. I was not surprised to see so much support for one of the two central arguments of the article: exclusion in global health is still very much the norm. But I was surprised about the lack of push-back on the second central argument of the article: even among those populations recently included in global health decision-making, discussions, and research, most representatives are highly privileged (they e.g. often tend to be highly educated, be part of a higher socio-economic class, live or have spent significant time in high-income countries, and have existing access to decision-makers).
Only one person contacted me to highlight that where a person is now may not reflect where they have come from or who they are. I have been thinking about this since. Is a focus on power and privilege too narrow? Should we also include the past? Or taken a step further, should we not only be looking at a person’s practical situation in the present, but also an imagined community they belong to, or self-identify with?
Let me first try to first reflect what this means for me personally. On the one hand, I am part of several underprivileged communities: I am a woman, a working mother, a foreigner in the country I live in, a person who does not live or work in my mother tongue, and my parents come from very simple rural contexts. On the other hand, I have very rarely if ever really felt excluded or discriminated against. I am from and live in a high-income country (both EU member states), my parents are highly educated, I am white, can travel and speak my mind freely, have been raised with principles and in a context that values both genders and equity, have a great education and work experience, have never experienced any financial hardship, and am fluent in several languages. Do I think I personally need to be proactively included, elevated, and supported? NO!
But just because I don’t think I need to be proactively included, and don’t feel excluded, does that mean that other women, working mothers, white people, or people whose parents came from very rudimentary socio-economic contexts should not be supported? Of course not. Here the complexity of identities, as well as the past kicks in, as does self-identification, and perhaps also compassion. Let me unpack this.
First, identities are complex. Just because I am a woman or working mother in a highly privileged context, this does not mean that others are too. There are poor women, single mothers, women with different ethnic backgrounds and skin colour, sexually harassed women, and women who have no rights or education. Many of these factors – especially when combined – exclude them and increase discrimination against them. Stories that these people tell usually include reminders that they had to work twice or multiple times as hard to simply survive, not give up, or make it to where they are today.
Second, the past also shapes who we perceive ourselves to be in the present, and we carry the knowledge and experiences of the past with us. In many countries, this may go back all the way to our ancestors, or great-grandparents. The US is a prime example here, where every biography or personal story seems to start with what came a generation if not several before us. Past and personal grit is central to the story of progress and success. In countries such as my own where equity plays such a large role (Finland), who your family is, where they came from, and what they achieved plays a much smaller role in shaping your opportunities, starting point in life, or identity. Humility is key, even for the successful. On the other hand, national history (e.g. independence struggles, women’s suffrage) is very present in education and national pride and culture.
Third, self-identification determines how we identify ourselves, even if it does not shape how others perceive us. Take the example of a white, middle-aged man working in an investment bank in London. To others, he’s just some norm. But he may strongly self-identify himself and be active in the LGBTQI community. Or in my own case, I identify less with women overall, because I have faced so little gender differences or discrimination in my own life, but identify strongly with working mothers. Self-identification and its strength can also change with time, or with experiences (a prime example is the Black Lives Matter movement, which has peaked and ebbed with time, but also broadened to include many non-black supporters and contracted with time). Self-identification may also be triggered by discrimination, or more subtle or proactive moulding by others (a great illustration of this is in Benedict Anderson’s book Imagined Communities, which explains how nationalism and the national identity came about, or has been imposed).
Finally, I strongly believe that compassion plays a strong role in anti-discrimination, inclusion and how you “spend your privilege”, as Blessing Omakwu so well outlines in this Devex article on equity in the international development sector. It’s not only about who you are and where you’ve come from, but people and stories that have moved you, and what you’re willing to give back, pay forward, or elevate and support when you are in the position to do so. For me, this means not only reflecting on my own privilege or facets of my identity that may be subject to discrimination, or fighting for other members of those groups (e.g. all women), it’s about having compassion for all of humanity, and elevating the stories and voices, and supporting the positions of those who truly are excluded, no matter what group or groups they may come from or be part of. This means that many of us who have a voice, a platform, a seat, should not claim to be representatives but work to hand over and share our privilege with others: this requires a willingness to pass and share the mic, to give up our seat, and to support and elevate those who need it.
All the articles, conferences, initiatives and debates on decolonisation, inclusion, diversity and equality are important. But to get inclusion and equity right, it’s important to unpack the complexity of identities, privilege, and power. Silver bullets and symbolic seats at the table, on boards, on a panel, in global health leadership positions, or as journal authors or editors won’t fix what we need to achieve. And the steps to get there in practice (e.g. changes to leadership structures and governance) are not simple either.
If you have good examples to share, or are working on these issues, please do share!
A few years ago, I was having dinner during the UN General Assembly with an inspiring global health colleague who is not afraid to speak his mind, and has a lot of experience and great lessons to share. I was feeling quite constrained in my job intellectually, and realized I was craving for some new thinking and thought leadership in global health. I asked my colleague to share suggestions of who is thinking outside of the box in our sector, who is not afraid to speak out, and who is truly interested in moving the needle on impact.
I have been following the work of these people and many more since, and the freedom of thought, research, and discussion I saw has been one of my inspirations to start writing (and thinking) again. I started asking myself what I really think and know about the issues I am working on, what my principles are, and where I personally think I can add value on – and have the space and support to do so.
I have throughout my career focused on diversity and inclusion in global health. Most of my positions have aimed to include the voices of unheard but affected populations into the global health discussion: children, adolescents, women, stigmatized people, and people who are discriminated against or ignored because they lack the financial means, citizenship or job to have their voices heard.
But I have also felt uncomfortable at times in how organizations or organizers of events (willingly or subconsciously) select representatives from these populations, or in the worst case dictate what they should say or how they should behave. In practice, this means that many such representatives have not been able to speak on behalf of the group they are there to represent, and their participation has been more tokenistic than real.
I have also at times represented such populations. I have been invited to speak because I am a woman, a working mother, or when I worked in civil society. I was supposed to represent people who are discriminated against and left out. I have tried to do so, by using a platform to highlight their challenges and issues. But have I been the right representative to speak on their behalf – with all of my own privileges, such as education, citizenship, geographic location, financial means, and my race? Or have I just been the token woman, CSO representative, etc? I admit I have often felt uncomfortable because of these questions I have asked myself.
I have seen these same challenges in my work throughout the years, for example in how many organizations deal with CSOs. It’s tick-the-box tokenism, and in the worst case instrumentalization. Both sides (the organization and representatives) bear some responsibility on how these relationships are used and abused, and it’s important also to call out that many representatives of underrepresented groups (women, CSOs, etc) greatly benefit from the access, visibility and perks they are given through their representation. The relationship easily becomes unhealthily symbiotic.
Because of these discomforts, I together with Ngozi Erondu and Madhu Pai (two great thought leaders in global health who are unafraid to speak their minds also on difficult issues) co-wrote an article in Think Global Health, Silenced Voices in Global Health.
We pose questions and discuss issues such as: What does real diversity mean and look like, and what will it take to get to real inclusion in global health? How can transparency help? And why do we need more critical self-reflection?
I am aware this is a difficult discussion to have. Many people really are underrepresented and discriminated again, stigmatization and discrimination are very, very real – as we can see even more poignantly again these days thanks to Covid19, and what is happening in the United States.
But we also need to make sure we are truly supporting those people who are discriminated against, not just pushing ourselves into the limelight because we share some attribute with other people. And we need to be transparent about who we really are, and what we can – or cannot – represent.
Katri Bertram 