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.


New paper released on the global burden of severe neonatal jaundice

While severe neonatal jaundice (SNJ) that is not successfully treated is rare in the U.S. and Western Europe, and thus often ignored as a global health problem, there is  evidence that SNJ is still a problem globally. In a paper co-authored by IH Section Councilor Dr. Mark Strand on the global burden of severe neonatal jaundice in newborns, the incidence of SNJ was found to be at 667.8 per 10 000 live births in the African region, where it is the highest, followed by Southeast Asia (251.3), Eastern Mediterranean (165.7), and the Western Pacific (9.4). This condition is easily diagnosed and inexpensive to treat and can save lives of children.

Read the rest of the research article here:

International Group B Strep Awareness Month: What Should I Know About GBS Disease?

July is International Group B Strep Month. This blog post gives an overview of the illness and its impact on pregnant women around the globe.

Group B Streptococcus bacteria (GBS), also known as Streptococcus agalactiae, typically colonize the gastrointestinal and genitourinary tracts, the throat, and the skin. GBS disease is caused when bacteria enter a normally sterile site such as the blood, bone, or spinal fluid. Both children and adults can develop GBS disease. The disease usually develops in infants that are 0-90 days old and adults that are 60 years of age and older with underlying chronic illnesses. There is currently no vaccine for GBS disease.

Although GBS may come from unknown sources, one out of four pregnant women are carrying the bacteria in their vagina or rectum and can vertically transmit an infection to their newborns. Infections occur during labor (“early-onset disease” or EOD) or within the first week of life through three months of age (“late-onset disease” or LOD). Symptoms can be difficult to distinguish from other infections and range from fever, difficulty breathing, lethargy, and “blue” skin. Severe symptoms that can develop in newborns and infants include sepsis and pneumonia. Meningitis is more likely to occur in infants or newborns with LOD. Complications from GBS disease may result in preterm delivery and lead to developmental disabilities or death. According to the Centers for Disease Control and Prevention (CDC), risk factors for pregnant women include:

  • Testing positive for group B strep bacteria late in the current pregnancy (35-37 weeks pregnant)
  • Detecting group B strep bacteria in urine (pee) during the current pregnancy
  • Delivering early (before 37 weeks of pregnancy) 
  • Developing a fever during labor
  • Having a long time between water breaking and delivering (18 hours or more)
  • Having a previous baby who developed early-onset disease

Since 1970, GBS disease has been a topic of concern in health care, research, and public health circles. In 1989, the death of three newborns from GBS disease led to the development of public awareness campaigns that called for improved education, detection, and preventive resources in the U.S. Furthermore, around this time, data collected by the CDC revealed that GBS disease was the leading cause of death in newborns. Parents and advocacy groups actively demanded guidance that would allow for routine screening and the development of an effective vaccine for pregnant moms, globally. Below is a timeline of how advocacy efforts led to research, policy change, and the implementation of effective interventions:

Brief Timeline of GBS Disease Awareness, Education, and Prevention Efforts

  • 1990 Group B Strep Association US/International is created. Its primary goals are to:
    • Educate the public about GBS infections.
    • Promote prevention of neonatal GBS infections through routine prenatal screening.
    • Promote the development of a GBS vaccine.
  • 1991 GBS researchers awarded a 5-year grant to begin research on a vaccine for  GBD disease
  • 1992 American College of Obstetrics and Gynecology and American Academy of Pediatrics publish position papers for members
  • 1996 CDC Call for Content on GBS Prevention Protocol in (January MMWR)
  • 1996 CDC, ACOG, AAP published first consensus statement on GBS National Prevention Guideline in June
  • 1997 Group B Strep Association launches its first website
  • 2002 The National Consensus Guidelines recommending routine screening for all pregnant woman was published
  • 2008 The CDC Active Bacterial Surveillance Core published data that showed an 80% drop in GBS neonatal morbidity and mortality
  • 2014 WHO convened the first meeting of the Product Development for Vaccines Advisory Committee (PDVAC); GBS and RSV identified as pathogens that cause a large burden of disease

Globally, it is estimated that EOD makes up 60-90% of GBS disease cases. The mean incidence of GBS disease in infants 0-89 days old is estimated to be .53 cases of GBS infection/1000 live births. The highest incidence of cases is reported to be in the continent of Africa, however, additional studies need to be conducted in low-income countries to better assess the true burden of disease. Prevention methods worldwide include providing prophylactic treatment (antibiotics) to women that are either high-risk or have tested positive for GBS, during labor. With treatment, there is only a 1/4000 chance of the baby becoming infected compared to a 1/200 chance if no treatment is given. In order to identify those who qualify for treatment, a culture-based method can be used to screen all pregnant women between 35-37 weeks for vaginal or rectal colonization of GBS. On the other hand, a risk-based method identifies pregnant women with risk factors for EOD such as fever, preterm delivery, and being in labor for 18 or more hours.

Although the administration of antibiotics during labor reduced EOD from .75 cases of GBS infection/100 live births to .23 cases of GBS infection/100 live births, GBS disease morbidity in infants and mothers is still significant and likely underreported. Antibiotic treatment and GBS disease education are more accessible to pregnant women in high-income countries than those in low-middle income countries. It is likely that challenges related to access to care and health system deficiencies limit the use of antibiotic treatment in low-middle income countries. As a result, the development of a cost-effective vaccine may be able to help bridge an awareness gap.

According to the World Health Organization (WHO), developing a vaccine for maternal immunization is a priority when it comes to GBS disease. In 2016, the WHO Product Development for Vaccines Advisory Committee held a technical consultation to discuss vaccine development. Ultimately, the committee determined that the global burden of GBS disease cases that result in stillbirths needs to be assessed. In addition, standardized antibody assays need to be developed in order to find correlates of protection. Vaccine targets such as the type III capsular polysaccharide (CPS) and proteins on the GBS bacterial surface have also been identified. As new vaccine development ideas for GBS disease are being discussed, here are some foundational components that the Group B Strep Association (US/International) and Group B Strep Support (UK/EU) groups feel have an important role to play in the introduction of the vaccine to pregnant women across the globe:

  • Standardized definition of disease worldwide.
  • Standardized monitoring of disease worldwide.
  • Routine prenatal care widely available in which a vaccine can be delivered.
  • Education of health professionals and parents and expectant parents about group B Strep and the vaccine.

Check out these CDC podcasts, if you want to learn additional information about GBS disease during International GBS Awareness Month!

The Year of the Girl

The United Nations declared October 11th the International Day of the Girl Child.  Everywhere I looked for this post’s inspiration, I saw story after story of the daily violence perpetrated against girls worldwide. I had to ask myself, why just a day?  Aren’t girls – roughly half of the world’s population – deserving of much more consideration? I say that we declare 2017 the YEAR of the Girl and devote our efforts to address the following issues.

Female Genital Mutilation

Female genital mutilation, or FGM, is a global concern. Some 200 million girls and women in 30 countries have undergone FGM, usually between infancy and 15 years of age. In many countries, FGM is a deeply entrenched cultural practice that has seen little decrease in the decades since foreign aid workers have been campaigning for is abolition. The risks might be high – infection, infertility, and complications of childbirth – but the perceived social benefits outweigh the physical costs. Bettina Shell-Duncan, an anthropology professor working as part of a five-year research project by the Population Council, has witnessed this conflict firsthand among the Rendille people of Northern Kenya:

One of the things that is important to understand about it is that people see the costs and benefits. It is certainly a cost, but the benefits are immediate. For a Rendille woman, are you going to be able to give legitimate birth? Or elsewhere, are you going to be a proper Muslim? Are you going to have your sexual desire attenuated and be a virgin until marriage? These are huge considerations, and so when you tip the balance and think about that, the benefits outweigh the costs.

Despite cultural ties, FGM is decreasing in some African countries as evidenced by rates from the prior generation.  However, with prevalence as high as 81% (Egypt), 79% (Sierra Leone), and 62% (Ethiopia), there is still much work to be done.


For example, with prevalence at 60-70%, FGM in Iraqi Kurdistan is a “hidden” epidemic.  Prevalence of this practice elsewhere in Iraq is 8%.  Outlawed in 2011 by the Kurdistan Regional Government under the Family Violence Law, FGM has continued largely unabated due to poor implementation and push-back from religious leaders.  You can read the Human Rights Watch harrowing report about FGM in Iraqi Kurdistan here.

Rape and Child Marriage

Last Friday, the BBC reported on a bill under consideration by the Turkish Parliament that would clear a man of statutory rape if he married his victim.  This bill is evidence of increasing violence against Turkish women.  Between 2003 and 2010, the murder rate of women increased by 1,400%.  Of course, the bill isn’t couched in terms of legalizing rape, but as a loophole for those offenders who know not the errors of their ways:

The aim, says the government, is not to excuse rape but to rehabilitate those who may not have realised their sexual relations were unlawful – or to prevent girls who have sex under the age of 18 from feeling ostracised by their community.

If passed, the bill would release 3,000 men from prison as well as legitimize child rape and marriage. Per Girls Not Brides, Turkey has one of the highest child marriage rates in Europe with 15% of girls married before the age of 18. Globally 34% of women are married before the age of 18 and every day 39,000 girls join their ranks. According to a study recently published in the International Journal of Epidemiology, child marriage comes with health and social consequences. Along with unintended pregnancies, infant and maternal mortality, and HIV, girls who are married suffer from social isolation, power imbalance, and experience higher lifetime rates of physical and sexual intimate partner violence.

Coming-of-age “Cleansing” Rituals

Practiced in parts of Africa, girls as young as 12 are forced to have sex as part of a sexual cleansing ritual.  The men, known as “hyenas,” are paid by parents to usher girls through the transition between girlhood and womanhood.  Girls are coerced into this practice through familial and societal pressure.  It is believed that great tragedy will befall the family and community should she not comply.  The use of a condom is prohibited.

A BBC radio broadcast found that communities believe the spread of HIV to be a minimal risk since they can pick men they know are not infected. One Malawian hyena, Eric Aniva, has been charged with exposing hundreds of girls and women to HIV. Aniva knew of his HIV status but did not disclose to his customers.

Forty percent of the global burden of HIV infections are in Southern Africa. Thirty percent of new infections in this area are in girls and women aged 15-24. Young women contract HIV at rates four times greater than male peers and 5-7 years earlier, linked to sexual debut or sexual cleansing rituals.

Let’s face it: Girls around the globe are being short-changed. Though progress has been made, there is still much work to be done. The Sustainable Development Goals have promised to “end all forms of discrimination against all women and girls everywhere” by 2030. Others attest that it will take at least another century for women to reach wage equity in the United States.  However it happens, rest assured it will take more than a day.

Female sterilization not an answer to global contraception

The last week of September marks two days dedicated to improving reproductive health: World Contraception Day  (September 26) and Global Day of Action for Access to Safe and Legal Abortions  (September 28).  Both days are committed to improving the reproductive health and choices of women worldwide. With the vision of making every pregnancy a wanted pregnancy, World Contraception Day aims to help the estimated 225 million women in developing countries who have an unmet need for contraception.

Reports such as the UN’s 2015 Trends in Contraceptive Use Worldwide include somewhat promising data, such as 64% of married or in-union women use a modern contraceptive method. This figure is lower in developing countries, including 17 countries in Africa where modern contraceptive use is below 20%.

Sterilization is the most widely used form of birth control, accounting for a third of modern contraceptive use. Sterilization is heavily weighted toward female sterilization, 18.9% versus 2.4% male sterilization globally.  In certain countries, the prevalence of female sterilization as modern contraception is much higher.  Female sterilization of sexually active women aged 15 to 49 is most prevalent in Latin America.  The Dominican Republic leads the pack at 47%  followed closely by Colombia, Costa Rica, El Salvador, and Puerto Rico.  China (29%) and India (36%) are also front runners.


Sterilization is a popular choice in the developed countries of Europe and North America, though male sterilization tends to be more prevalent than in the developing world. When practiced safely, sterilization offers many benefits because it is a one-time procedure with no follow-up or maintenance.  While sterilization might be the best choice for some individuals or couples, unsafe, involuntary, or otherwise coercive female sterilizations are altogether too common and an affront to human rights.

China’s “one child” policy  – perhaps one of the more infamous anecdotes in mandated family planning – has relied on sterilization to meet its goals.  In the heyday of the 1980s, neighbors became informants on so-called “out-of-plan” pregnancies.  Offending families were fined and possessions stolen, and local bureaucrats oversaw countless forced abortions and sterilization. 1983 alone saw over 20 million sterilizations. China’s Communist Party has recently relaxed its one-child policy  to allow each couple two children, but many in China, including activist Chen Guangcheng don’t see the difference as stated in this tweet:

This is nothing to be happy about. First the #CCP would kill any baby after one. Now they will kill any baby after two. #ChinaOneChildPolicy

Lesser known is an Uzbekistan policy that assigns gynecologists a sterilization quota of up to 4 per month.  In a report by the BBC, rural women who have had two or more children are the main target of this campaign.  It is estimated in 2011 alone that 70,000 Uzbek women were sterilized, some voluntarily and some involuntarily.  Unlike China’s policy to slow population growth, Uzbekistan’s goal is to manipulate its once abysmal infant mortality ratings.  Fewer infants means fewer infant deaths, and Uzbekistan’s infant mortality rate in 2012 is half of what it was in 1990.

India has received much attention for its sterilization camps.  The name alone conjures images of the Nazi eugenics movement.  In 1951, with Malthusian ideology in mind, an Indian demographer set out across rural India to complete a census.  His prediction – that India’s population would reach 520 million people by 1981 – was both incorrect (India’s population in 1981 was 683 million ) and the catalyst for a mass sterilization program.  This led to compulsory sterilization in 1976  that lasted for 21 months and effectively sterilized 12 million men and women, often rural, poor, and of low caste.  Employment, wages, and even running water were withheld from individuals and whole villages until 100% compliance was met.

Today, while technically voluntary, sterilization in India is incentivized. In the past, men were promised transistor radios in exchange for a vasectomy.   Male sterilization is now considered culturally unacceptable.  Women are the target of sterilization campaigns and can receive up to $23 US – a month’s income – to submit to a tubal ligation.

Women undergo sterilization operations at the Cheria Bariarpur Primary Health Centre in the Begusarai District of Bihar. A few dozen women were sterilized in one day. Although India officially abandoned sterilization targets years ago, unofficial targets remain in place, according to people working on the ground. One Primary Health Centre doctor says the targets in themselves are not necessarily the problem, arguing instead that itÕs the lack of a good healthcare infrastructure in some places that makes it difficult to safely meet those targets. SARAH WEISER

Indian women arrive at sterilization camps by the jeep load.  In makeshift operating theaters –  with no electricity and running water – neither gloves nor equipment are changed between the five-minute operations.  Expired antibiotics given to some women are found laced with rat poison.  In 2014, Dr. R.J. Gupta, self-described as performing 300 tubal ligation in one day, was arrested after women he and an assistant sterilized either died or were hospitalized.  The current government regulation is that no one doctor should perform more than 30 sterilizations a day.  On the day in question, Gupta’s six-hour spree resulted in 83 tubal ligation.  It is believed that Gupta was trying to reach a government-set target of 220,000 sterilizations in one year.

On September 14th of this year, India’s Supreme Court ordered a close of all sterilization camps within three years.  That is an unsettling time span in which over a half a million more women could be sterilized and many more deaths and hospitalizations could occur.  Even after the dissolution of government-sanctioned sterilizations camps, women will continue to be subject to this dangerous procedure.

What are low cost, accessible, and humane forms of birth control for the developing world?  A promising alternative might be Sayana® Press, a lower-dose presentation of the three-month injectable contraceptive Depo-Provera® in the Uniject™ injection system.

A village health worker counsels a client in family planning and administers Sayana Press. Phiona Nakabuye (left), village health worker trained by PATH’s Sayana Press pilot introduction program, with Carol Nabisere (right), age 18, who chose to receive Sayana Press after being counseled in the various forms of contraception, Kibyayi village, Mubende district.

Original trials of the injectable contraceptive were successful in Florida, New York, and Scotland, and the same seems to be holding true in Uganda.  Most women were able to self-administer the drug after just one training session and again at the next dose, three months later.  Designed for single use, Sayana® Press reduces reliance on needles and needle sharing  which is essential in the fight against HIV/AIDS and women only need to travel to a clinic once to get a year’s supply.

There is so much to consider when it comes to global family planning.  It would be remiss not to mention the impact that the HIV/AIDS epidemic has on sterilization rates in some regions of the world and you can read more here, here, and here.  Organizations such as USAID have been implicated  for funding so-called fertility reduction programs that include mass sterilization.  What can be done to ensure all women have access to contraception?