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The field of public health is historically framed within Western, white, and patriarchal ideals. Much of the representation in leadership, research, and treatment is not reflective of the populations being served. While there are efforts to rectify these gaps, they are not necessarily sustainable or sufficient.
Some organizations such as Women Lift Health and the Women Leaders in Global Health Initiative have adopted equity initiatives geared toward providing training, mentoring, and resources to the individuals that did not have access to such resources earlier in their lives (1,2). In parallel, Global Health Initiatives (GHIs) have emerged in the global health field as “new models of development assistance in the fight against diseases in low and middle- income countries over the past decade” and have been identified as having “the potential for making a major impact on health systems at country level, by improving access to health services, prevention, treatment, care and support for specific diseases”. Like local and domestic efforts, recommendations have put forward to adjust GHIs to better alleviate health outcome inequities, such as assessing the impact of different interventions on social inequities or address GHI impacts on health systems and human resources to name a few (3). Nonetheless, GHIs still perpetuate health outcome inequities by holding control over funding and task delegation, thus highlighting a need for more than case-by-case support and going further by implementing systemic changes that create more equitable opportunities for individuals of all backgrounds to utilize.
Incorporating a justice lens, on top of on-going equity initiatives, to public health would contribute not only towards alleviating daily health disparities but also to reconstructing the foundations of the public health infrastructure. A justice lens is defined as applying initiatives that target and address systemic barriers and obstacles as a means of ensuring that anyone, regardless of race, gender, nationality, etc., have equal opportunities and access. A justice lens of public health could help to address the limitations of an equity lens acting alone, which frequently relies on treating issues on a case-by-case basis without addressing the root issues. It would also be relevant in emergency situations such as natural disasters, infectious outbreaks, and more by fixing underlying public health systems and removing the practices and policies that act as barriers to certain groups of people, like racial, ethnic, gender, and sexual minorities.
By overhauling the restrictive, unrepresentative systems on which many organizations still operate, a more fair and inclusive structure could take place, thus creating a fairer health system in all aspects of operation.
While advancements in medicine have certainly contributed to increased lifespan and wellbeing, the importance of addressing the social determinants of health has also gained greater attention. Studies have indicated that there are strong associations between a “wide range of health indicators and measures of individuals' socioeconomic resources or social position, typically income, educational attainment, or rank in an occupational hierarchy” (4). For example, higher levels of educational attainment are associated with greater life expectancy in both men and women, as well as lower percentages of adults aged 25–74 years reporting poor/fair health across racial/ethnic groups (4). Additionally, such relationships observed between socioeconomic factors and diverse health outcomes may also reflect “gradients in resources and exposures associated with socioeconomic factors”, as well as the impact of an individual’s subjective social status, thus demonstrating the interplay between resources and wellbeing (4). Therefore, overcoming the barriers that stem from social determinants of health is something that a justice centered lens is well suited to address.
When considering gender representation in health systems in particular, women make up half the population and almost 70% of the health and social care workforce, female representation in health leadership is not representative of that breakdown, with women only comprising 25% of leadership roles (5). Going up the leadership ladder, female representation drops significantly among senior management and upper leadership, and those limitations to entering leadership roles is only further exacerbated by factors like race, religion, class, and more (5). Representation in health research is also unbalanced with women being underrepresented in clinical trials and health issues like premenstrual syndrome receive far less research focus when compared to issues such as erectile dysfunction (6). Despite making up a significant portion of the population administering healthcare, women are consistently unrepresented in the decision-making processes and research focuses that determine what health issues are given attention and precedence.
The COVID-19 pandemic has magnified the disadvantages that women face with regards to providing and receiving healthcare. Women are more likely to be exposed to COVID as they are likely to be the ones responsible for caring for loved ones. Female healthcare providers frequently faced long, intense shifts while outfitted with “insufficient or inadequate personal protective equipment” but were barely represented on major COVID taskforces (7). Furthermore, female researchers made up only 34% of authors with regards to COVID-related papers8. Research from the University of Cambridge has suggested that female academics “were more risk averse and less willing, as well as less able as a result of extra domestic work, to start new projects at short notice” (8). COVID has shed light on challenges and barriers the female health professionals continue to face, and it is apparent that regulations and support must change to address these issues expeditiously.
Moreover, another area of inequity and disparities is evident when comparing the Global North and Global South. Global public health is deeply rooted in colonialism, with Western interests being framed as the norm and deciding how and where funding and assistance should be allocated. In global health governance, 72% of global health leadership positions are concentrated in North America and Europe, while representation across all the Global South is only 20% (9). When excluding insights from low-income nations, it results in the loss of “essential talent, knowledge and expertise, with serious implications for pandemic preparedness, progress on Universal Health Coverage and meeting the health-related targets of the Sustainable Development Goals” (9). Thus, it is difficult to address local issues effectively when the global health leaders and initiatives responsible for leading such efforts have been guided and framed by colonial institutions, thereby interfering with the actual needs of the community in question.
Within the context of the COVID-19 pandemic as well, countries throughout the world have demonstrated imbalances in the care and resources that are provided. Lower- and middle-income countries frequently faced barriers to conducting effective testing programs, protecting frontline healthcare workers, and providing more robust medical services for patients with more severe cases (10). In addition to people living in lower middle-income countries (LMICs), millions of lower-income individuals living in high income countries also face “significant barriers to self-protection due to crowdedness, poor housing conditions and poor sanitation”, as well as loss of employment and housing (10). Additionally, the Strategic Advisory Group of Experts on Immunization stated that while vaccine inequity is decreasing, “high-income countries have administered 69 times more doses per inhabitant than low-income countries” (11). This disparity is evident as the World Health Organization (WHO) noted that 31.4 million doses, or 2% of the population, have been administered in 50 African nations, compared to the UK where 40 million people, or 70% of the adult population, have received at least one dose (11).
Common initiatives that are used to combat inequity include setting and tracking gender parity quotas, implementing training and mentoring programs in professional spaces, and emphasizing early education. However, such initiatives are still rooted in power imbalances between the appointed trainers and mentors and the people they are supposed to guide. With both acute and long-term examples, it is apparent that equity initiatives alone are insufficient in addressing gaps in health care provision and reception. Therefore, integrating a justice lens in parallel would push for public health organizations to go beyond delegation and resource allocation, to unlearning colonial practices and developing systems that center around the needs and input of the community in question, including the billing and use of local institutions over their direct involvement. By integrating justice-focused practices and initiatives, health outcomes influenced by the social determinants of health can be addressed directly to improve outcomes for generations to come.
The benefits of having justice initiatives in tandem with equity initiatives stem from the increased appreciation and understanding of the concept of intersectionality. Kimberlé Crenshaw coined the term “intersectionality” in 1989 to bring attention to the oppression that African American women face due to their simultaneous identities of their race and gender (12). As she outlines, intersectionality is "a lens, a prism, for seeing the way in which various forms of inequality often operate together and exacerbate each other” (13). She goes on to explain that we “tend to talk about race inequality as separate from inequality based on gender, class, sexuality or immigrant status” and that the piece that’s “often missing is how some people are subject to all of these, and the experience is not just the sum of its parts” (13). While equity initiatives may target individual aspects of a person’s overall identity, what justice initiatives would seek to address is removing barriers that individuals of multiple intersecting identities encounter.
Furthermore, there are several reasons why encompassing an intersectional focus by implementing justice initiatives can be beneficial. Making it easier for people with differing life experiences to enter leadership spaces will bring forth more holistic and unique perspectives and ideas. Thus, these perspectives can “facilitate and inform the development of well-targeted and cost-effective health promotion messages, interventions, and policies” (14). By taking an intersectional focus and “embracing rather than avoiding the complexities that are essential to understanding social inequities”, it is possible to stop health inequalities in treatment before they develop into more serious issues (14).
It is also important to consider the divide between organizations centered around addressing public health issues and the actual populations that are impacted by the issue in question. Local interests may be doing important public health work for considerable lengths of time, but risk being pushed aside by larger global organizations with more recognition and resources, especially financial assets and established networks with other larger scale organizations. Rather than superseding authority over local efforts, letting local organizations dictate what resources and actions are needed could improve the working relationship between global and local interests, rather than creating unnecessary conflict and competition.
To address discrepancies in representation in both the provision and reception of health services, organizations must go further than striving for equity and should adopt a justice lens. Equity alone does not account for the additional challenges that individuals of differing racial, ethnic, and socioeconomic backgrounds face on top of their gender identity. While equity is certainly a good starting point, a justice-centered lens should be the true objective for public health organizations and governing bodies should simultaneously pursue justice-focused initiatives.
In practice, a justice lens of public health could be applied in several ways:
• Let local interests and organizations decide where to direct funding from external sources
• Diffuse power from solely within senior leadership authority among various levels of authority, especially including local and community figures (ideally of differing backgrounds) to be directly involved in decision making processes and stakeholder meetings
• Revamp the hiring process, going with options like blind hiring processes, representative interview panels, etc.
• Include root case analysis in public health equity programming so that corrective measures address the cause of deprivations
• Monitor representation in leadership, power, research, funding, etc. and set targets that reflect a distributive representation
• Build regional and local institutions in the south that are resourced and equipped to lead public health efforts. As a part of this, decrease the incentives and behaviors that result in the preservations of global institutions at the expense of regional and local institutions.
• Systematize organizations' inclusion of training and awareness building on the impact of subconscious bias on equity, justice and power for all staff
While justice seeks to rectify underlying systemic issues, equity initiatives are still needed to ensure that non-systemic barriers are also addressed. Both socioeconomic barriers to entering and climbing the leadership ladder and individual circumstances, like physical limitations, need attention and action.
In addition to providing resources and support for individuals from disadvantaged backgrounds, an emphasis on correcting the issues within existing institutions and systems is necessary for long-term, sustainable change to become a reality. A justice lens to public health could look like a division of power among a representative group of leaders instead of one CEO or following the lead of local NGOs and community initiatives instead of delegating instructions to them. The main point is that organizations cannot rely on resource provision alone to narrow gaps in parity and must strive to reevaluate and actively improve underlying systems. By having justice and equity initiatives working in tandem, individual and systemic barriers can be addressed, therefore opening more opportunities for individuals of any background.
1. Gupta, G. (2021, June 15). Who We Are. Retrieved from https://www.womenlifthealth.org/ourmission
2. Women Leaders Initiative. (n.d.). Retrieved from https://www.womeningh.org/women-leaders-inglobal-health
3. Hanefeld, J. (2008). How have global health initiatives impacted on health equity? Promotion & Education, 15(1), 19-23. Retrieved from http://ezproxy.cul.columbia.edu/login?url=https://wwwproquest-com.ezproxy.cul.columbia.edu/scholarly-journals/how-have-global-health-initiativesimpacted-on/docview/233340473/se-2?accountid=10226
4. Braveman, P., & Gottlieb, L. (2014, January/February). The Social Determinants of Health: It's Time to Consider the Causes of the Causes. Public Health Reports, 129(Suppl 2), 19-31. doi:10.1177/00333549141291s206
5. World Health Organization. (2019). Delivered by women, led by men: a gender and equity analysis of the global health and social workforce. World Health Organization. https://apps.who.int/iris/handle/10665/311322. License: CC BY-NC-SA 3.0 IGO
6. Slawson, N. (2019, December 18). 'Women have been woefully neglected': Does medical science have a gender problem? Retrieved from https://www.theguardian.com/education/2019/dec/18/womenhave-been-woefully-neglected-does-medical-science-have-a-gender-problem
7. Gharib, M. (2020, June 24). Where the women aren't: ON coronavirus task forces. Retrieved from https://www.npr.org/sections/goatsandsoda/2020/06/24/882109538/where-the-women-arent-oncoronavirus-task-forces
8. Hunt, K. (2020, June 18). How female scientists are losing out during the pandemic and why it matters. Retrieved from https://edition.cnn.com/2020/06/18/health/coronavirus-research-gender-biasscn/index.html
9. Global Health 50/50. (2021). Gender Equality: Flying blind in a time of crisis, the global health 50/50 report 2021. https://globalhealth5050.org/wp-content/uploads/Global-Health-5050-2021-Report.pdf?v2
10. Shadmi, E., Chen, Y., Dourado, I., Faran-Perach, I., Furler, J., Hangoma, P., Hanvoravongcahi, P., Obando, C., Petrosyan, V., Rao, K.D, Ruano, A.L., Shi, L., de Souza, L.E., Spitzer-Shohat, S., Sturgiss, E., Suphanchaimat, R., Uribe, M.V., & Willems, S. (2020). Health equity and COVID-19: Global perspectives. International Journal for Equity in Health, 19(1). doi:10.1186/s12939-020-01218-z
11. Burki, T. (2021). Global COVID-19 Vaccine Inequity. The Lancet Infectious Diseases, 21(7), 922-923. doi:10.1016/s1473-3099(21)00344-3
12. Kimberlé Crenshaw on Intersectionality, more than two decades later. (2017, June 8). Retrieved from https://www.law.columbia.edu/news/archive/kimberle-crenshaw-intersectionality-more-twodecades-later
13. Steinmetz, K. (2020, February 20). Kimberlé Crenshaw on what intersectionality means today. Retrieved from https://time.com/5786710/kimberle-crenshaw-intersectionality/
14. Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—an important theoretical framework for Public Health. American Journal of Public Health, 102(7), 1267-1273. doi:10.2105/ajph.2012.300750