Achieving health equity in global health through workforce diversity

This International Women’s Day we honor the achievements of women leaders working to advance the health and well-being of people all over the world. Their path to success was certainly not easy. It was fraught with numerous challenges; challenges that are not only experienced by those of us working in global health but by women across all industries.

We are considered either too soft and feminine or too bossy and pushy to be seen as competent leaders. Our work culture lacks family-oriented, work-life balance policies which enable us to contribute to our field in significant ways. We lack female mentors to encourage us to grow and push us to overcome any obstacles we encounter in our career. We work for organizations where the people who make the big decisions on what policies and programmatic areas to focus on are men. The struggles we face trying to advance in our careers are reflected in the lack of gender equality in the global health workforce. While women make up 70% of the global health workforce, only 25% of leadership positions in global health are held by women.

We have known for a long time that when women are given equal opportunities for leadership at all levels of decision-making in economic, political, and public life, everyone in society does better. Female leaders in health “promote access to contraceptives, empowerment programs for girls, women’s rights to family planning and maternity care, safe abortions, and protecting environmental assaults on children’s health.” In addition, women leaders at all levels of governance have shown to be the primary driver toward financing public goods such as health, education, hospitals, clean water, and sanitation. Women’s participation and leadership in economic, political, and public life is so critical to advancing societies that it is even written into one of the sustainable development goals. When women have a voice at all levels of decision-making, we are closer to eliminating the inequities that lead to disparities in health.

More global health organizations are recognizing the need for women leaders and organizations such as Women in Global Health are working toward achieving gender equality in global health leadership. Last year the World Health Organization’s newest Director-General, Dr Tedros Adhanom, appointed eight women to senior leadership, effectively outnumbering the men. In doing so, he took one big leap toward achieving gender equity at the WHO – a goal that was first set in 1997 and that took two decades to realize.

Gender equality is not the only type of diversity we need to strive toward in our global health leadership however. Diversity in global health leadership must also focus on inclusion of people from different ages, race and ethnicity, sexual orientation, social class, geography, religion, and other characteristics of personal identity.  As a woman and a first-generation Filipino-American working in global health in the United States, I often find myself at global health and public health conferences and meetings wondering why there are very few leaders that encompass the diversity that I represent on stage (and occasionally even in the audience). The people who make the decisions with the biggest impact in global health must reflect the diversity of the people we serve.  

Learning from, understanding, and seeing the world through another person’s point of view is at the heart of working in global health and a driving reason for why I chose to work in this field. In order to truly reflect the diversity of this field though, the definition of diversity itself needs to go far and beyond the characteristics of one’s personal identity. To fully be inclusive, we must also be open to learning from, understanding, and seeing the world through the perspectives of individuals in the global health workforce with diverse backgrounds, life experiences, and competencies. Our field could benefit from the ideas of diverse individuals in solving some of the world’s most pressing global health problems. These ideas cannot always come out of our own echo chambers. 

Achieving diversity in the global health workforce is everyone’s job. It requires each one of us to recognize and overcome the personal biases (whether they are subconscious or not) which prevent us from hiring and working with more diverse talent. For those of us responsible for making decisions, we must work to create policies at all levels which not only promote but require inclusion. It’s only then that we can achieve true diversity in our workforce and our leadership. It’s only then that we can progress further in achieving health equity.

Stay tuned for part two of my series on Achieving health equity in global health through workforce diversity in which I will discuss different ideas for how we can achieve diversity in the global health workforce.

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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.

CSIS Event and Virtual Webcast: Careers in Global Development, October 4th

Center for Strategic and International Studies and the Project on U.S. Leadership in Development cordially invite you to:

Careers in Global Development

To get more information and to register, click here.

Date: Wednesday, October 4, 2017

Time: 9:00 a.m. to 10:30 a.m. ET

Location: CSIS Headquarters, 1616 Rhode Island Ave NW, Washington, DC 20036

Virtual webcast available

Featuring

Gregory Gottlieb

Director of the Feinstein International Center at the Friedman School of Nutrition & Policy, Tufts University

Moderated by

Ambassador William Garvelink

Senior Adviser
Project on U.S. Leadership in Development, CSIS

“Careers in Global Development” is a monthly series featuring U.S. senior-level, multilateral and NGO officials who have worked in the field of development for at least twenty years. The series is aimed at young professionals who are interested in working in development and will include a one-hour dialogue on both the specific expertise of the speaker, as well as the career path and influences along the way. It will focus on specific areas of interest, including the role of humanitarian assistance in development and U.S. foreign policy; development as a tool to counter violent extremism; and sectoral issues such as food security, health, and education.

This session features Greg Gottlieb, recently appointed Director of the Feinstein International Center at Tufts University.  Throughout his distinguished career, Greg has worked to improve food security, humanitarian, and transition programs. Most recently Greg served as the Acting Assistant Administrator for the Bureau for Democracy, Conflict, and Humanitarian Assistance at the United States Agency for International Development (USAID/DCHA). Prior to that, he served as the Senior Deputy Assistant Administrator for DCHA. Since he began with USAID in 1988, he has held a variety of other positions, including Mission Director in Pakistan and Namibia, Senior Deputy Assistant Administrator for the Bureau of Food Security (helping to plan and implement the Obama Administration’s Feed the Future Program), as well as posts in Malawi, Sudan, Ethiopia, and Kenya. Greg earned a bachelor’s degree from Humboldt State University, a Juris Doctor from Loyola Law School, and a Master’s in Public Policy from Harvard University’s Kennedy School of Government.

Please note that RSVP is NOT necessary should you be attending the virtual webcast. 

IHSC career development webinar recording “En Route from the Ebola Tent to Congress” now available

The APHA International Health Student Committee hosted a webinar called “En Route from the Ebola Tent to Congress” on September 27, 2017 with Deborah Wilson, RN and MPH candidate at Johns Hopkins Bloomberg School of Public Health. Debbie led an interactive webinar walking attendees through a day in the life of an Ebola Treatment Center, including a bit about the political fallout upon returning to the USA, and how her experiences shifted her from direct patient care to public health policy.

If you have any questions, please email: apha.ihsc.careers@gmail.com

International Health Student Committee (IHSC) Career Development Webinar

Join the APHA International Health Student Committee for a Career Development webinar with Deborah Wilson, RN, and MPH candidate at the Johns Hopkins Bloomberg School of Public Health for a discussion of her recent experiences in the Ebola “hot zone.”

September 27th, 2017 @ 5:30 pm

Click here to register. Contact – apha.ihsc.careers@gmail.com

 

sept webinar