(Mis)Represented. Our Global Health is UnGlobal.
Global health is all but global, says Fifa Rahman, Permanent Representative for NGOs for the WHO-backed ACT-Accelerator

The appointment of Ngozi Okonjo-Iweala, the former Nigerian Finance Minister, World Bank development economist and its former Vice President, and black African woman, as head of the WTO, has been heralded as ‘a big deal’, an inspiration, and ‘a sign of the many strides (Africa) has made in gender parity’. While all this is true, and while representation is important, it is but one step towards tackling pervasive racism in global health. 

On 25th February 2021, twenty black and brown leaders in global health, including implementers, academics, civil society, and communities living with the diseases, will convene in a virtual roundtable to discuss how racism and white supremacy affects global health governance, hiring, and programming. This roundtable, convened by Matahari Global Solutions, a global research and policy group, and the AIDS and Rights Alliance of Southern Africa (ARASA), will define the parameters for an in-depth study to take place this year – and advocacy meetings with global health agencies. A meeting report will be published and sent directly to heads of key global health agencies. 

COVID-19 Impact of Race on Health

The COVID-19 pandemic has brought to the fore clear disparities in infection rates, death rates, and access to diagnostics, vaccines, therapeutics, and care for black and brown communities. It’s a bleak reminder of the enduring inequity in global public health.  As early as April 2020, one Brookings Institute article pointed out that the COVID-19 response does not take into account the fact that black individuals in predominantly white geographies are more likely to live in areas with ‘lack of healthy food options, green spaces, recreational facilities, lighting, and safety’, and that black people are more likely to live in densely populated areas. 

In addition, COVID-19 tools are not well adapted to dark skin, with pulse oximeters showing misleading readings 12% of the time in persons with non-white skin. And contrary to what was expected, Global North responses to COVID-19 have not necessarily been the most efficacious nor the most effective. For example, the United Kingdom, the United States, and Sweden failed to adequately protect their populations, while global south countries such as Rwanda and Taiwan effectively instituted systems and deployed technologies to respond effectively to the pandemic. Yet in the Global Health Security Index, the United States and the United Kingdom were ranked first and second in the world in terms of pandemic preparedness. This underscores the need for us to decolonise and redefine global health and address existing power imbalances within global health structures and debates. 

Racism as a Systemic Issue Through Organisations

The white Global North perspective is inherent in global health. Yet only recently has the impact of race and whiteness on global health governance, hiring, and programming come into focus. Anu Kumar, CEO of IPAS, a non-profit working across Africa, Asia, and the Americas on reproductive rights, asked in a June 2020 op-ed, “Why do we in the global health sector, which is dominated by white people, especially white women, believe that we know how to solve the health problems of people in other countries?” 

Stephanie Kimou, who has worked extensively on sexual and reproductive health in francophone Africa, commented in a separate op-ed: “[A]t work, nobody looked like me. The person who started the nonprofit, the finance manager, the operations person — all white. All the major money and programmatic decisions — all made by white people being driven around in fancy cars and living in gated communities. It was so clearly neocolonialist.”

At its very basis it may seem to the untrained eye that this is solely an issue of hiring more Black, Indigenous and people of colour.  We need to recognize that there is intersectionality of oppression and inclusion. However, as mentioned above, tokenistic diversity hires will not address the philosophy behind why black and brown people, in particular women, don’t get hired in the first place. These are entrenched within culture and everyday practice. In the words of Anu Kumar, “What we don’t talk about is how the structures and operations of our organizations are part of white supremacist culture.”

What defines global health deliverables and decision-making is membership. Covert racism means that while the parameters of membership go largely unsaid, it is white people that are seen to be reliable and responsible for important documents that guide implementation of programs, setting guidelines on how many diagnostic tests should be deployed to countries that need them, etcetera. White people are considered most suitable to respond to emails promptly, to feedback more eloquently in project design, are promoted into leadership positions and thus get to represent the views of black and brown implementers. This is the de facto modus operandi, even if it would never be uttered in such plain language.

Real Examples – Race and Whiteness in Global Health

2020 presented several examples of institutional white supremacy culture – notably, how structures and institutions are structured to uphold white dominance. In June last year, a Médecins Sans Frontières internal statement highlighted that while 90% of its staff were hired locally in countries where MSF works, most of its operations were run by European senior managers. So based on absolute numbers alone diverse hiring doesn’t appear to be the issue here. But of course it is an issue when, much like colonial times, positions of power are overwhelmingly filled by white people. 

MSF insider Arnab Majumdar wrote last year about MSF senior managers assuming national staff were ‘intellectually lazy’, explicitly referring to them as being ‘vulnerable to corruption’. Complaints of racism were met by the accusation of ‘reverse racism’, a recognized signifier of white supremacy. And while the MSF core executive committee responded by saying they would address the difference in compensation in their teams, and that they would continue to address broad issues of harassment, abuse, and discrimination within the organisation, nothing public has emerged since that time on the effects of this work. 

Also in June 2020, the Women Deliver CEO, Katja Iversen, took a leave of absence after allegations of a toxic work environment, including racist comments about hair of black women, black people being refused for hire multiple times, and that the organisation suffered from a ‘white saviour’ complex. Four months later, reports emerged of the conclusion of investigations into racism at Women Deliver – that no single person was responsible. The verdict was slammed as a ‘slap in the face’, and was accompanied with critique that Women Deliver ‘doesn’t really know what accountability is’. 

A similar situation transpired at the International Women’s Health Coalition – with a letter being published on racist and toxic culture within the organisation, the President resigning as a result of the allegations, but with investigations clearing the President and senior managers of racism – finding instead that there was a ‘pervading culture of fear and intimidation’.

These white-centred power structures result in widespread race-based oppression within organisations and within health systems. Priorities are distorted, sociocultural reasons for disparity in healthcare are ignored and/or misunderstood, and new health technologies end up not being culturally appropriate nor equitably efficacious. Dolutegravir, a major HIV drug on the WHO Essential Medicines List, was predominantly trialled on white populations, missing out key genetically diverse populations. In November 2019, the ADVANCE trial found the risk of major weight gain among black women.  Has the system learned from such mistakes? No. Moderna proudly advertised that in its Phase 3 COVE trials for the new COVID-19 vaccine 28% of study participants were from “diverse communities” – i.e. 72% were white. Conversations within the WHO Access to COVID-19 Tools Accelerator (the ACT-Accelerator), specifically designed to bring necessary vaccines, diagnostics, therapeutics, PPE, and oxygen supplies to countries most in need – have been dominated by white individuals from the Global North, leaving a knowledge deficit among countries that would receive these technologies. 

The Way Forward

COVID-19 is showing the world with renewed urgency that representation and participation is essential in formulating public health responses. It is for this precise reason that Matahari Global Solutions and AIDS and Rights Alliance for Southern Africa (ARASA) have embarked on an ambitious project to document the various effects of a lack of diversity and white supremacy, on global health programming, hiring, and governance. 

With a small amount of funding from Open Society Foundations, we’ll start with a roundtable with black and brown leaders in global health, then conduct an in-depth qualitative study to ascertain how whiteness is experienced in global health. Results will be publicised widely – and discussed directly with key global health agencies. We still have to secure funding for a larger quantitative study of over 300 individuals, and advocacy missions by organisations in the Global South on distorted priorities and colonialist global health, to Geneva and New York-based decision-making bodies. But this work is a start. 

Racism, white supremacy, and colonialism echo through our global health. The system is unglobal and misses out on equitable representation. Colonialist, (un)global health doesn’t work and it needs to change. 

Fifa A Rahman is principal consultant at Matahari Global Solutions

Dr Fifa A Rahman is the Permanent Representative for NGOs on the Diagnostics Pillar and the Facilitation Council of the ACT-Accelerator, and principal consultant at Matahari Global Solutions; Felicita Hikuam is Director at the AIDS and Rights Alliance of Southern Africa; Nyasha Chingore-Munazvo is Programmes Lead at the AIDS and Rights Alliance for Southern Africa; and Gisa Dang is Associate Consultant at Matahari Global Solutions. 

Image Credits: Fifa Rahman.

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