The inevitable inequity of unpaid internships

A few years ago, the story of a UN intern from New Zealand living in a tent by Lake Geneva made international headlines. Apparently Geneva residents, along with the rest of the world, were “shocked that the famous and much-loved institution should be connected to such a case.”

The only thing that shocked me was that so many were unaware of this ugly reality that is a persistent infection of the international development industry.

I have extremely strong opinions about unpaid internships. Part of this may stem from my generation’s collective rage toward the economic disaster into which we were dumped after finishing university, and our resulting economic desperation. Unpaid internships are certainly not unique to global health or international development, and the Great Recession left us particularly vulnerable to them.

Most of my frustration, however, comes from the fact that this trend is particularly strong in global health – a field which is ostensibly focused on building up health systems to support the poorest and most vulnerable. I discovered that, despite being the child of a first-generation immigrant with fluency in both Portuguese and French (on top of an MPH), my financial inability to work in unpaid positions (read: I don’t have rich parents) turned out to be a permanent barrier to entering a field that I was so passionate about. Dozens of applications went unanswered over the years even as my resume accumulated increasingly advanced public health jobs in the U.S. The only explanation I could think of was the catch-22 that plagues the industry. You can’t get jobs doing development work unless you already have closely related experience doing development work – which means that the first few times are unpaid. Multiple well-known development professionals have confirmed this, and most appear to have just accepted it as an unfortunate reality. My experience is not unique.

This irony of using unpaid interns to drive the entry-level work of global health is finally beginning to creep into the peer-reviewed literature. As an editorial in last month’s Lancet Global Health pointed out about WHO’s internship program:

[WHO’s] mandate, to promote the health of people worldwide, requires it to build technical and operational skills within the health systems of its 193 member states. For many of these states, particularly those of low income that face growing disease burdens, developing skills in the next generation of public health professionals is imperative.
WHO’s Internship Programme exists to support this goal. …However, less than 20% of interns come from developing countries. This imbalance in member state participation has two principal causes: an absence of financial support for interns, which precludes the participation of many from low-income and middle-income countries; and an ad-hoc recruitment process that favours candidates with connections in well-established academic institutions, typically in high-income countries. The result is a missed opportunity for WHO and inadvertently undermines its own objectives on human resources for health.

Oh, unpaid internships restrict the pipeline of global health professionals to rich people from rich countries? Shocker.

Many aspiring global health professionals (including myself) have groused about this reality, swapping anecdotes of spreadsheets of rejected applications and job boards glutted with positions requiring at least a decade of experience. But ground-level conversations between those of us on the outside looking in don’t move the needle. To have any chance of addressing the problem, the first step is establishing that it exists across the industry – and an excellent way to do that is with data.

The Global Health Jobs Analysis Project was born out of a pair of conversations I had at the 2015 Annual Meeting in Chicago with IH Section members who shared my frustrations. After exchanging similar stories of scouring hundreds of job vacancies for non-expert positions, to no avail, we resolved to put together a team to collect and analyze data on a job market that most global health MPH grads simply cannot crack. Two years, a thousand job vacancy descriptions, and six months of peer review later, our analysis was published in the open-access journal BMC Public Health. From the abstract:

We analyzed the data from 1007 global health job vacancies from 127 employers. Among private and non-profit sector vacancies, 40% (n = 354) were for technical or subject matter experts, 20% (n = 177) for program directors, and 16% (n = 139) for managers, compared to 9.8% (n = 87) for entry-level and 13.6% (n = 120) for mid-level positions.
Our analysis shows a demand for candidates with several years of experience with global health programs, particularly program managers/directors and technical experts, with very few entry-level positions accessible to recent graduates of global health training programs. It is unlikely that global health training programs equip graduates to be competitive for the majority of positions that are currently available in this field.

Our analysis is related to the unpaid internship problem because it shines a light on the “top-heavy” nature of the global health employment field. In a typical industry or discipline, you would expect to find the largest number of positions at the entry level, with increasingly fewer mid-level, managerial, and technical expert or director positions. Our data – which only included paid positions – showed the exact opposite. There were more director-level positions than managerial spots, and nearly half of the positions were for technical experts. This certainly lends weight to the Lancet Global Health editorial’s suggestion that the vast majority of the initial work needed for “developing skills in the next generation of public health professionals” is unpaid. This assumption even appeared in our peer review, when one of our reviewers asked why we didn’t include internships in the analysis:

Why not include unpaid internships in the study? Aren’t these ‘entry-level’ in a way? Knowing about the prevalence of internship jobs would help better characterize the potential mismatch between graduate programs and job markets.

Our response:

We deliberately excluded unpaid positions because they are not available to all
applicants in the U.S. global health employment market. While they may technically be entry-level positions, they do not provide candidates with the means to support themselves or their families. […] Such positions are effectively restricted to applicants with a working spouse, affluent families, and/or independent wealth.

There is something perverse about an industry that restricts careers doing meaningful work helping the poor to a small handful of extremely wealthy people, no matter how well-intentioned. The end result is that program beneficiaries cannot enter the industry and thus end up having no say in how those programs are designed, administered, or evaluated. Equally important is the consideration that an industry overwhelmingly staffed by people with the same backgrounds will inevitably suffer from the lack of diverse experiences and perspectives. Again, global health is not the only field that suffers from this cancer, but the stakes in this line of work are incredibly high. A WaPo editorial on the same phenomenon on Capitol Hill raises these very questions:

What consequences arise when Congress effectively restricts its entry-level workforce to those willing to take on debt via credit cards or those for whom money is no object? It almost certainly makes it more difficult for the child of a teacher [to pursue] the ultimate public service career.

If the only way to thrive in Washington is by way of someone else’s bankroll, how can those entrusted to find policy solutions to this country’s problems come from anything lower than the upper middle class?

How indeed.


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