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.

Advertisements

Progress toward #polio eradication is a much-needed reminder that global health is still winning

I always love spotlighting polio eradication. Along with Guinea worm, it is one of the few candidates to follow smallpox to the eternal (or so we all hope) halls of eradicated diseases. While the eradication effort has suffered its setbacks in recent years, public health workers have persisted, steadily marching onward. And frankly, there has been so much hand-wringing in global health in recent weeks that it is important to occasionally remember that there are still wins we can, and should, celebrate.

What makes this success possible in addition to trackable is the global network of polio surveillance systems, which was featured in CDC’s MMWR at the beginning of April:

The primary means of detecting poliovirus transmission is surveillance for acute flaccid paralysis (AFP) among children aged [less than] 15 years, combined with collection and testing of stool specimens from persons with AFP for detection of WPV and vaccine-derived polioviruses (VDPVs)…in WHO-accredited laboratories within the Global Polio Laboratory Network. AFP surveillance is supplemented by environmental surveillance for polioviruses in sewage from selected locations. Genomic sequencing of the VP1-coding region of isolated polioviruses enables mapping transmission by time and place, assessment of potential gaps in surveillance, and identification of the emergence of VDPVs. For public health nerds like me, all of MMWR’s polio reports can be found here.

Basically, a combination of syndromic and environmental surveillance allows public health systems to track polio where it pops up, and genetic sequencing helps to trace how the virus got to where it did to shed light on transmission patterns and find gaps in surveillance.

The WHO followed with two YouTube videos featuring the global polio surveillance system and polio vaccination, which is what will make eradication possible:



This is all pretty straightforward stuff – we all know generally that surveillance systems do, in fact, work when their infrastructure is properly supported and that children should be vaccinated against polio. But it’s important to not lose focus on our successes and global health progress, even when it is simple, straightforward, and sometimes slow.

Engaging our members: Results of the 2017 Member Engagement Survey

At the beginning of March, the International Health Section sent out a membership engagement survey put together by the Membership, Communications, and Global Health Connections Committees. The survey was sent out over the APHA Connect e-mail listserv and individually to all members who provided an e-mail address with their APHA member profiles. We collected responses for approximately three weeks and closed data collection after about three weeks, on March 25.

Thank you to all who responded! We have been working to analyze the data and discuss the feedback we received. We want our members to know that we are taking this feedback seriously and actively working on changes to our communications and approach to member engagement in response. We hear you loud and clear!

A summary report of the survey responses and the committees’ action plan are included below. You can access this report, as well as an Excel spreadsheet and a Tableau workbook summarizing the survey response data, in the Section’s library on APHA Connect. (You will need to log into Connect using your member ID, so be sure to have it handy.


2017 Member Engagement Survey Results: A Summary
April 21, 2017

Methods
On March 6, a 19-question member engagement survey was sent out over APHA Connect and individually to all members included on the March 1 roster provided by APHA. Of the 2,368 members, 43 did not list an e-mail address, and 61 e-mail addresses were invalid, meaning that the survey link was sent to 2,264 recipients. We received 230 responses between March 6 and March 25, a 10% response rate.

Overview
Of all survey respondents, nearly two-thirds (62%) listed the IH Section as their primary affiliation, compared to 38% with IH as their secondary Section. By membership category, 43% were regular members (full, discounted, or affiliate), 33% were students, 18% were Early Career Professionals (ECPs), and 6% were retired. Primary members (62% of respondents vs. 45% of all members) and ECPs (18% of respondents vs. 11% of all members) were over-represented among survey respondents. Most (86.5%) indicated that they intended to renew their APHA membership.

Consistent with overall membership data, nearly half (45.5%) of respondents had been members for less than a year, and an additional 28% had been a member for 1-3 years. The most common reason listed as the primary motivation for joining APHA was networking (48.7%), followed by professional collaboration (“to connect with other researchers/professionals to collaborate on studies/projects,” 21.3%). Nearly a quarter of respondents indicated that they joined to either attend (13.5%) or present (11.3%) at an Annual Meeting.

Committees and working groups
Members were given the opportunity to indicate if they were interested in learning more about the Section’s committees and working groups, and to provide their e-mail address for the chairs of their selected committees and working groups to reach out to them with information on how to get more involved. Committees that generated the most interest among respondents were Advocacy/Policy (36.5%), Mentorship (23%), and Program (21.3%). Working groups with the largest number of interested respondents included Global Health Connections (46.5%), Maternal and Child Health (27.4%), and Community-Based Primary Health Care (25.7%). Committee and working group selections were not mutually exclusive, as respondents could indicate multiple committees and working groups in their form response.

Communications
Survey respondents seemed to be largely unaware of the Section’s communications platforms. Among the four platforms in the survey, awareness of APHA Connect (https://connect.apha.org) was highest (38.6%), followed by the quarterly Section Connection newsletter (33.1%), the Section’s social media channels (30.2%), and the blog/website (https://aphaih.org, 28.8%). Respondents were most likely to actively read the newsletter (20%) and follow the Section’s social media channels (8.9%).

Discussion and follow-up
The general tone of most of the responses was that members want to get more involved but aren’t sure how, and that our communications channels are not advertised well enough. The Membership, Communications, and Global Health Connections Committees have developed a list of action items, found on the next page, to address the needs indicated by the survey responses.

Action Items

Completed items

  • Distribute e-mail addresses of respondents who were interested in committees/working groups to the respective committee/WG chairs (March 27)
  • Share initial survey results with the Section leadership (March 31 conference call)
  • Make survey data and results analysis available to members in the following formats (April 21):
    1. Written report
    2. Spreadsheet
    3. Dashboard
  • Publish the results of the engagement survey on the IH Blog and the APHA Connect listserv (May)

Ongoing items

  • Include links to APHA Connect, the blog, and all social media channels on all newsletters
  • Promptly send out welcome e-mails to new members when the Membership Committee receives new rosters

Items in development

  • Publish the results of the engagement survey for all members in the Section Connection newsletter (July)
  • Create a checklist for members and present it as a 6- to 12-month program to acquaint them with the IH Section and APHA (June)
  • Host a short webinar to “tour” our social media channels, APHA Connect, old issues of the newsletter, and leadership contact information (August)

Policy on #HIV related travel restrictions adopted by @WFPHA_FMASP at #WCPH2017 now posted

After APHA adopted its permanent policy statement on HIV-related immigration restrictions that we submitted at last year’s Annual Meeting, the IH Section worked with APHA’s WFPHA liaison, Dr. Deborah Klein-Walker, to submit a corresponding policy proposal on behalf of APHA to the World Federation of Public Health Associations, which held its 15th World Congress on Public Health this month in Melbourne, Australia. The proposal was accepted and passed by the WFPHA Policy Committee at the meeting, and has now been posted the website (PDF). The text of the policy (excluding references) is below.

Scientific evidence and treatment needed to combat the spread of HIV – not ineffective travel bans

Submitted by the American Public Health Association
(Contact person D. Walker)

Introduction
HIV-related restrictions against entry, stay, and residence remain common around the world. Various countries have policies that mandate HIV testing of all or certain groups of foreign nationals as a condition of obtaining a visa for employment. These policies have no basis in science and violate migrant workers’ human rights to confidentiality and informed consent to testing, exposing them to exploitation by their employers. According to UNAIDS, 35 countries currently have official HIV-related travel restrictions. Furthermore, HIV-related travel restrictions against foreign nationals have been shown by international treaty bodies, international legal scholars, and human rights organizations to constitute discrimination based on race, ethnicity, and/or country of origin.

Scope and Purpose
Restrictions on travel, immigration, or residence related to HIV status are a violation of the principles of nondiscrimination and equal treatment in all international human rights laws, treaties, and agreements. The International Covenant on Civil and Political Rights guarantees the right to equal protection under the law, free from discrimination based on race, color, sex, language, religion, political or other opinion, national or social origin, property, birth, or other status, and the UN Commission on Human Rights has determined that this includes discrimination based on health status, including HIV infection. According to the Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, while international human rights law allows governments to restrict rights in cases of emergency or serious public concern, the restrictions must be the minimum necessary to effectively address the concern – and HIV-related travel restrictions have been overwhelmingly ruled as both overly intrusive and ineffective public health policy. Within such restrictions, compulsory HIV testing is a serious violation of numerous human rights principles, including the right to bodily integrity and dignity. The accompanying deportation and/or loss of employment and residency status of HIV-infected migrants that frequently accompanies such testing violates the rights of PLWHA to privacy, work, and appropriate medical care. The International Labour Organization (ILO) has specifically stated that neither HIV tests nor private HIV-related personal information should be required of employees or job applicants.

Despite this robust evidence base, according to UNAIDS, 35 countries currently have official HIV-related travel restrictions openly acknowledged and enforced by the government. These restrictions vary from outright entry bans, which bar PLWHA from entering the country, to restrictions on stays longer than a specified period of time or to obtain employment visas or residency status. Others have inconsistent policies and/or intentionally misrepresent their policies with HIV-related restrictions. Such policies and practices, and the number of migrants impacted by them, are difficult to track because of differing or ambiguous definitions and a lack of data. Some of the most restrictive policies subject immigrants to mandatory HIV testing, either when applying for residency or for an employment visa, which is frequently required by states for legal residency.

The two primary justifications provided by governments for mandatory HIV tests for migrant workers and other HIV-related travel restrictions are to protect public health and reduce the cost burden on the country’s healthcare system imposed by providing HIV care services to foreign nationals. While countries have the right to employ measures to protect their populations from communicable diseases of public health concern, HIV is not transmitted by casual contact, meaning there is no scientific basis for attempting to control its spread via immigration policies. Furthermore, countries that do not have HIV-related travel restrictions have not reported any negative public health consequences compared to those that do, and recent analysis suggests that even migration from countries with generalized HIV epidemics does not pose a public health risk to destination countries.

In fact, immigration policies banning or restricting entry or employment based on HIV status often have the opposite effect of their protective intention, causing direct harm to the health of both of immigrants and citizens. They marginalize PLWHA, regularly discourage people from accessing HIV testing and treatment, and reinforce stereotypes and discriminatory attitudes against PLWHA in the general population. Regulations requiring HIV tests of immigrants can promote the idea that foreigners are dangerous to the national population and a public health risk, as well as creating a false sense of security by reinforcing the notion that only migrants are at risk for infection. Additionally, such attitudes can adversely impact the host country’s own HIV epidemic, as citizens who are unaware of their HIV-positive status, underestimating their own HIV risk and avoiding testing due to stigmatization, are more likely to transmit the virus to others, driving up infection rates.

State-enforced HIV screening of migrants costs far more than it saves in treatment costs. Screening travelers and migrants for HIV is impractical and expensive.[5][13][19] Labor migrants (both regular and undocumented) bring significant economic benefits to their host countries, in addition to themselves, and this cost-benefit balance remains even when migrants are HIV-positive and rely on the host country’s health care system for treatment and support.

Fields of Application:

  • National public health associations and their members
  • Human rights and HIV advocacy groups
  • UNAIDS
  • The World Federation of Public Health Associations

Action Steps:

The WFPHA joins with UNAIDS, the World Health Assembly, and other HIV and human rights organizations (e.g., Amnesty International, Human Rights Watch, ILO) to call on all countries that still maintain and/or enforce HIV-related restrictions on entry, stay, or residence to eliminate such restrictions, ensuring that all HIV testing is confidential and voluntary and that counseling and medical care be available to all PLWHA within its borders, including migrants and foreign nationals.

The WFPHA affirms the following principles:

  • All people have the right to confidential and voluntary HIV testing and counseling.
  • Persons living with HIV/AIDS (PLWHA) have the right to privacy, to work, and to appropriate medical care.
  • All HIV-related travel and immigration restrictions currently in place should be removed.
  • Agencies and businesses who employ foreign nationals should not use HIV tests as a means to discriminate against potential employees.
  • Governments should provide HIV prevention and treatment services that are equally accessible to citizens and foreign nationals.
  • Migrant workers should have access to culturally appropriate HIV prevention and care programs in languages that they can understand.

The WFPHA recommends that:

  1. Public health associations in every country should:
    1. Develop policies opposing HIV-related travel restrictions;
    2. Document and/or support human rights and HIV advocacy groups in documenting immigration policies that explicitly discriminate, or allow employers to discriminate, against migrants based on HIV status;
    3. Document and/or support human rights and HIV advocacy groups in documenting any HIV testing practices that are not voluntary or confidential;
    4. Inform their members and the public that HIV-related travel restrictions and compulsory HIV testing of foreign nationals is a violation of human rights and does not protect public health or reduce health care costs; and
    5. Advocate for the removal of any and all HIV-related travel restrictions enforced or condoned by their country governments.
  2. UNAIDS should take steps to ensure that its protocols to research and investigate countries’ HIV-related travel restrictions are sufficiently thorough by monitoring and documenting any reported instances of HIV-related discrimination targeting immigrants, particularly when presented with evidence demonstrating that recognition of a country’s removal of HIV-related travel restrictions is unwarranted, in order to ensure that governments are not able to misrepresent their policies in order to gain undeserved recognition for supporting human rights with regard to HIV/AIDS.

WFPHA supports the removal of all HIV-related travel restrictions and travel related mandatory testing.

#D4CA Challenge: UN Global Pulse calls for research proposals to analyze business data to combat #climatechange

Note: This was cross-posted to my own blog.


Rose Schneider, chair of the IH Section’s Climate Change & Health Working Group, shared this information about the Data for Climate Action challenge. It’s an initiative by the UN’s Global Pulse to recruit researchers and data scientists to “leverage private big data to identify revolutionary new approaches to climate mitigation and adaptation” – that is, use corporate datasets, which have been de-identified and made available by participating companies, for projects or analyses that “generate innovative climate solutions.” According to the press release:

Data for Climate Action will target three areas relevant to the United Nation’s Sustainable Development Goal on climate action (SDG 13): climate mitigation, climate adaptation, and the linkages between climate change and the broader 2030 Agenda.

The challenge aims to generate original research papers and tools that demonstrate how data-driven innovation can inform on-the-ground solutions and transform efforts to fight climate change. It builds upon the model of data science competitions pioneered by organizations like Kaggle, and company-specific initiatives to share big data for the public good, such as the “Data for Development” challenges hosted by Orange.

Researchers who are selected to participate in Data for Climate Action will have four months to conduct their research. A diverse panel of experts in climate change and data science will evaluate final submissions based on their methodology, relevance, and potential impact. Winners will be announced in November of 2017.

The data being offered includes retail transaction data, social media posts, meteorological and air quality data, and user-generated data on road conditions. Data sets can be combined with each other or with other publicly available datasets like those featured on Data is Plural. Individuals or teams can submit proposals, and the only apparent requirement is that all participants be at least 18 years old.

They’ve apparently extended the deadline from April 10th to the 17th, so any analysts or programmers who aspire to code for the public good still have ten days to get their applications together and apply.