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Why are things the way they are? On the need to go beyond representation and think politically about inequities

By Sana Contractor
on November 30, 2018

Over the past few weeks, I have been following, with some discomfort occasionally, the conversations around women’s leadership in global health, taking place in the context of the Women Leaders in Global Health Conference (WLGH) at the London School of Hygiene and Tropical Medicine. We must be concerned that most of the conversation on gender and the health workforce in the global arena is still limited to talking about representation, even if an open letter penned by young women asking for greater intersectional representation in the conference steering committee, is no doubt a step ahead. Earlier in October this year, I had the privilege of speaking at the closing plenary at the Fifth Global Symposium on Health Systems Research in Liverpool, where I reflected on our preoccupation with “who” is left behind, rather than the processes that perpetuate inequity. With that intervention, I was hoping to highlight that the project to address inequities is an inherently political one, but runs the risk of being watered down by being reduced to a numbers game (as often seems to be the case in the SDG era). The topic of women’s representation in the workforce suffers from a similar problem in that, the problems of the (mostly female) health workforce, are much more structural and daunting. The reason for the precarious conditions of health workers, particularly those at the bottom of the pyramid who tend to be women, is rooted in larger questions of down-sizing, starving the public sector of funds, contracting out of services in the name of efficiency, and so on. It would be pertinent for us to look beyond representation therefore, and perhaps ask the more important questions of why things are the way they are.

This is not to say that representation is not important. Indeed, the lack of women in leadership is a problem, and the lack of women from the global south is an even bigger problem. Women from the global south, working in the global south, may be more representative than white women from the north, but let us also recognize the reality of post-colonial societies, which have their own share of inequities and hierarchies. In India, where I come from, for instance, medicine, media and indeed the non-profit sector, consists typically of upper caste, upper class men and women, who also represent their own interests. This recognition is important in global health, and indeed for those of us who claim to represent the global south. Ultimately, it is the political positions that we take, and the extent to which we are able to question the structures that prop us up that matter most.

In some sense, this tension is representative of the troubling ambiguities and contradictions that currently exist in the mainstream discourse on inequities in global health, which needs reorienting. The current focus of solutions to address inequities is to find ways to “include” the most vulnerable, but fails to question or even understand these inequities in a meaningful way. Part of this is due to the target driven global agenda, especially since the turn of the century, but actually already before that. Hence the solutions tend to pick low hanging fruit through targeting or financial incentives, which are utilitarian at best and coercive at worst. Inequities cannot be tackled in such a myopic manner – what health systems need is to engage with the causes of inequities themselves, beginning with understanding the pathways through which inequities are produced. The framework(s) that we choose to use, in order to make sense of inequities, is/are where the politics of one’s work lies. Scholars and philosophers representing counter-hegemonic traditions and movements can help in this regard. What can we learn from Ambedkar about caste disparities in health in India, or what can Fanon teach us about mental health, for instance? How do we make sense of the exclusion of indigenous populations without an understanding of their fraught relationship with the state, and indeed their struggles?

I suspect that part of the reason for why we do not ask these questions, is because it cuts to the heart of the privileged positions that we ourselves occupy. Talking about inequity cannot be a conversation just limited to understanding who is “left behind”, but must become a conversation about who is at the front, in the driver’s seat. (The overall SDG agenda has skirted around this problem and avoids addressing wealth inequality, or even government spending on health as an indicator for addressing UHC). Focussing only on those who are left behind does a disservice in two ways:

1) it has a tendency to make little compartments where every excluded group – women, indigenous people, sexual minorities, people with disabilities, migrants, fragile and conflict affected – wants its own corner, thus pitting us against one another even as we often embody more than one of these vulnerabilities, and leaves us fighting for a limited piece of the pie and 2) it exonerates those who actually do get the (much) larger portion of the pie. During the post-MDG discussions, I recall reading a somewhat satirical comic which wondered if we could consider a target like “ending extreme wealth” instead of “ending extreme poverty”. It struck me as particularly relevant to the world in which we live – even as each one of us wants no one to be left behind, it is unclear whether anyone is willing to “give up” anything, for this to actually happen. Even in our own work, we often end up reinforcing social hierarchies – reflected in the asymmetry of power in research collaborations, our complicity in top-down policy making and the preoccupation with influencing policy makers with evidence, without recognizing the power of social movements and communities.

If we are serious about ending inequities, we must therefore start looking at where power lies – either in the form of capital, or in the social hierarchy. Understanding how inequities are produced is critical to ending them, and those who produce and benefit from the inequities need to be held accountable. Otherwise, the project of “leaving no one behind” can become an exercise in targeting, and end up missing the wood for the trees.


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