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.


Global News Round Up

Politics & Policies

Last week, Bill and Melinda Gates released their 10th annual letter, focused on the 10 toughest questions they receive in their work. To mark the occasion, the heads of the Bill & Melinda Gates Foundation’s three global programmatic areas – Global Development, Global Growth & Opportunity, and Global Health – answer the toughest questions they are asked.

UHC (universal health coverage) is defined as a situation where “all people can obtain the health services they need, of good quality, without suffering financial hardship.” These broad definitions leave lots of room for specifying how decentralization and UHC governance might interact.

Programs, Grants & Awards

Seattle’s Center for Infectious Disease Research announced Tuesday that it has received a new,$17.2 million grant from the National Institute of Allergy and Infectious Diseases to fund its research into TB (tuberculosis), a persistent and deadly disease in many parts of the world.

A  multidisciplinary team of scientists from Baylor College of Medicine, Harvard Medical School and Utrecht University have been shortlisted for Cancer Research UK’s grand challenge award.


Researchers have identified a new family of antibiotics, malacidins, by using gene sequencing to analyze more than 1,000 soil samples in the US.

Elderly study participants who had positive beliefs about aging were 44% less likely to develop dementia than those who held negative beliefs over the course of 4 years, a new study shows.

Diseases & Disasters

A drug commonly used to control high blood pressure may also help prevent the onset of type 1 diabetes in up to 60 percent of those at risk for the disease.

Monkeys in Brazil are being illegally killed for fear they might help spread yellow fever.

Defeating measles has long been a cherished dream in global health. Just in 2016, according to the World Health Organization, the disease infected more than 20 million people and killed almost 90,000 children.

The World Health Organization has sent a six-person team and 40 boxes of personal protective gear to help fight a major outbreak of Lassa fever in Nigeria.

More people have taken their own lives in Northern Ireland since the Good Friday agreement than were killed in political violence during the Troubles between 1969 and 1997, the latest regional figures on suicide reveal.


A new tissue paper based wearable sensor has been engineered to detect a pulse or a blink of an eye. The researchers say that these light, flexible, inexpensive sensors could be used for a variety of applications.

Environmental Health

A class of chemicals called perfluoroalkyl substances (PFASs) used in many industrial and consumer products may be associated with greater weight gain after dieting particularly among women, a new study shows.

Increased neighborhood walkability has been found to be significantly associated with lower blood pressure and decreased hypertension risk among residents.

Equity & Disparities

A new study has found that there is lower access to private health care in areas with high mobile phone ownership. Additionally mobile phones base health care seems to discriminate against poorer households.

Cash transfers through emergency food security program are helping rebuild livelihoods in Sierra Leone after the Ebola epidemic.

Maternal, Neonatal & Children’s Health

An international charity warned on Monday that 4.7 million children across East Africa risk dropping out of school this year due to malnutrition arising from displacement sparked by drought and conflict.

More babies are dying each year in West and Central Africa even as child health improves overall, aid agencies said on Tuesday, calling the region’s newborn death rate a “hidden tragedy.

Don’t forget to submit your abstract to APHA’s 2018 Annual Meeting!

Submit an abstract to present at APHA’s 2018 Annual Meeting and Expo taking place in San Diego from November 10-14.  Deadlines are soon and range from February 19-23. See the list of components here for specific deadlines.

Abstracts related to all areas of public health, especially those that correspond with the Annual Meeting theme “Creating the Healthiest Nation: Health Equity Now,” are welcome! Download and review a PowerPoint with detailed instructions and advice for submitting an abstract.

If you’d like to submit to the International Health component, the deadline to submit is February 23rd. This year we seek a broad range of entries on global health related to the session topics listed below, as well as entries related to the overall meeting theme.


  • Advocacy in Global Health
  • Child Survival and Maternal and Child Health
  • Climate Change and Global Health Issues
  • Community Based Primary Health Care
  • Displaced Populations and Refugee Health
  • Emerging and other Infectious Diseases
  • Global Health Financing and Policy-Related Issues
  • Global Health and Human Rights
  • Global Urban Health Issues
  • HIV/AIDS – Global Issues
  • Malaria, Vector-Borne, and Neglected Tropical Diseases
  • Mental Health – Global Issues
  • Monitoring, Evaluation, and Quality Improvement
  • Non-Communicable Diseases – Global Issues
  • Nutrition and Malnutrition
  • Reproductive Health and Family Planning
  • Social Determinants of Health
  • Special Panel on Student-led Global Health Projects
  • Strengthening Health Systems In Developing Settings
  • Training, Human Resource Development and Global Workforce Issues
  • Women’s Health


2/14 Webinar: WASH and Nutrition Interventions for Child Growth and Development: Results from the WASH-Benefits and SHINE Trials

WASH and Nutrition Interventions for Child Growth and Development: Results from the WASH-Benefits and SHINE Trials

February 14, 2018
12:30 pm- 2:30 pm

Organized by the Water and Health GPs, World Bank

WebEx Link
Number: 732 597 473
Password: JhTY6FGQ


Enteric infections are known to contribute to poor growth and development in children under two years, and can be reduced with optimal water, sanitation and hygiene (WASH).  However, the direct link between WASH and child growth is less understood. The WASH-Benefits and the SHINE Trials, both recently completed, studied the impact of WASH and nutrition interventions delivered alone and in combination to test for synergistic effects on child growth and diarrhea in the first two years of life. These trials used similar study designs, enrolling pregnant women in rural Bangladesh, Kenya, and Zimbabwe and following their children during the first 18-27 months of life.

The results of the trials are very consistent: although the nutrition interventions modestly improved growth, the WASH interventions did not have independent effects on growth, nor did they strengthen the effect of the nutrition intervention when delivered in combination. In contrast to prior studies and the WASH interventions in Bangladesh, the WASH interventions in Kenya and Zimbabwe did not significantly reduce diarrhea.

What does this mean for current and future WASH, nutrition and health programming? Join us for presentations on these findings and a lively discussion on what’s next for WASH and nutrition.

Session Chairs:
Timothy Evans
Senior Director
HNP Global Practice

Guang Zhe Chen
Senior Director
Water Global Practice

Dr. Clair Null
Senior Researcher
Mathematica Policy Research and Co-Principal Investigator of WASH Benefits, Kenya

Dr. Jean H. Humphrey
John Hopkins Bloomberg School of Public Health and Principal Investigator of SHINE, Zimbabwe

David Evans
Lead Economist

Meera Shekar
Global Lead, Nutrition
HNP Global Practice

Presenter Bios:
Dr. Clair Null is a Senior Researcher at Mathematica Policy Research and a Research Affiliate at Innovations for Poverty Action. Previously, she was an Assistant Professor in the Hubert Department of Global Health at Emory University’s Rollins School of Public Health and a Fellow at the Radcliffe Institute for Advanced Study at Harvard University. She holds a Ph.D. in Agricultural and Resource Economics from the University of California, Berkeley.

Dr. Jean H. Humphrey, Professor, John Hopkins Bloomberg School of Public Health and Principal Investigator of SHINE, Zimbabwe

Contact information of Organizer
For more information about this event please contact Luke Gates at

Global News Round Up

Politics & Policies

The notion of a shared responsibility to prevent global public health emergencies caused by disease epidemics is hardly new.  The history goes back to the 1851 International Sanitary Conference in Paris that followed the cholera epidemics in Europe between 1830 and 1847.

The Centers for Disease Control and Prevention’s (CDC) dwindling pot of money aimed at fighting infectious-disease epidemics like Ebola will run out this year, and the agency doesn’t anticipate new dedicated funds. So the CDC is scaling back epidemic prevention work in 39 countries, and this has experts, including a United Nations Dispatch on Friday, saying “you should be freaking out.”

It has now been a little more than a year since President Donald Trump, on his first full day in office, reinstated the Mexico City Policy, also known as the “Global Gag Rule,” and a picture of its impact is beginning to emerge.

It was a financial investment in a tobacco company that helped lead to the downfall of Brenda Fitzgerald, who until Wednesday was the director of the Centers for Disease Control and Prevention.

The draft 13th General Program of Work cut across discussions at last week’s 142nd executive board session of the World Health Organization.  But while some stakeholders perceived progress on the current draft, questions remain, including the nagging question on how WHO Director-General Tedros Adhanom Ghebreyesus would be able to finance his vision for the organization.

International health campaigners and alcohol concern groups called on a major global HIV and malaria fund on Thursday to end immediately a partnership it had signed with the Dutch brewer Heineken.

Programs, Grants & Awards

US Alumni Global Health Workshop brought together 22 alumni from US government exchange programs from African nations to share best practices for public health communication.

Paul Farmer, co-founder and chief strategist of Partners in Health, will receive the National Academy of Sciences most prestigious Public Welfare Medal this year.


Researchers from Harvard T.H. Chan School of Public Health have identified a gene associated with lower asthma risk and its role in the disease’s progression — findings that open a new potential pathway for treatment.

Daily use of marijuana as well as past month rates rose for both men and women aged 26 and older in states with medical marijuana laws in effect.  Marijuana use among those younger than 26 years old was generally unaffected by changes in the law.

The results from the largest ever study of septic shock (a life threatening illness that occurs when the body’s response to infection leads to low blood pressure that reduces blood flow to vital organs and tissues such as the heart, brain, kidney and liver) could improve treatment for critically ill patients and save health systems worldwide hundreds of millions of dollars each year.

Diseases & Disasters

Every single year, a group larger than the entire population of Seattle die from heart disease.  While these 846,000 annual fatalities are only half of what they were in 1980, cardiovascular disease is still the leading cause of death in the United States.

Urgent action must be taken to stop the spread of drug-resistant malaria in south-east Asia and potentially beyond, according to scientists. The outbreak in Cambodia, then Thailand, Laos and most recently Vietnam, of malaria that is untreatable with the newest and best drugs we have has alarmed experts. There have been calls for the World Health Organisation (WHO) to declare a public health emergency of international concern, as it did with Ebola in west Africa and Zika virus in Brazil.

Due to fears over Dengue vaccine, parents in the Philippines are refusing to vaccinate their children for tetanus, chicken pox and polio.

There have been 22 deaths and about 2000 cholera cases in seven African countries since the beginning of 2018. The increasing numbers of cholera cases are being blamed on poor sanitation and hygiene.


What if reaching the United Nations Sustainable Development Goals on access to health for all depended on the willingness of all actors to see beyond outdated dichotomies. The concept may seem obvious, but is easier described than done. In an effort to break silos, the Swiss Federal Institute of Intellectual Property (IPI) brought together stakeholders of all sides last week to discuss how to harness political and economic will to achieve innovation leading to new medicines that are available and affordable for all in need.

In an effort to stop diabetes patients from progressing to dialysis phase, doctors and researchers in Japan have launched a large-scale clinical study to examine whether internet connected medical devices and a smartphone app could help maintain blood sugar levels.

Environmental Health

Hundreds of tonnes of colistin, the strongest “last resort” antibiotic known to medicine, are being shipped to India to be used on chickens that may not even require the drugs.

Hyperthermophilic composting may have the potential to reduce the abundance of antibiotic-resistance carrying bacteria from composting end products.

Equity & Disparities

Equity in health is the notion that everyone should have a fair opportunity to reach his or her full health potential.  A focus on equity can strengthen the link between health and other development sectors by focusing attention on the most vulnerable populations. If certain populations are continually underserved by their health systems and experience a disproportionate impact, it endangers the well-being of societies at-large and can even hold back health progress for the most advantaged.

A new study has found that blacks, Hispanics and low-income students are at most likely to be exposed to air pollution. The study reveals that in 5 of the 10 worst polluted school counties, over 20% of the population is non-white.

Maternal, Neonatal & Children’s Health

In a new study of childhood mortality rates between 1961 and 2010 in the United States and 19 economically similar countries, researchers report that while there’s been overall improvement among all the countries, the U.S. has been slowest to improve. Infants in the U.S. were 76 percent more likely to die.

Recent studies indicate that infants born prematurely have a higher risk of developing heart disease later in life.  Now, researchers at the University of Washington School of Medicine in Seattle have shown that, in preterm animal models, inflammation due to infection can disrupt the activity of genes crucial for normal heart development.