Opinion: Turning the tide in development — an inclusive response to COVID-19

As media headlines became dominated with news that COVID-19 had reached Europe and North America, there were claims that it was the “great equalizer.” It was a threat that would not discriminate along the lines of historical markers of power and privilege.

It was not long before this characterization was widely debunked. On the contrary, it is hard to recall a time when disparities in individuals’ access to health, safety, and economic security were so vivid.

The coronavirus mortality rate is over four times higher for Black people compared with white people in the U.K. and 2.3 times higher in the U.S. Those living in unsafe domestic environments face exacerbated threats, with the United Nations Population Fund estimating an additional 15 million cases of intimate partner violence globally from an average lockdown of three months. The virus has been used as a pretext for arrests of and violence against LGBT people in Belize and Uganda.

As research professor Cynthia Enloe has said of this pandemic: “We aren’t all in this together. We’re all on the same rough seas together, but we’re in very different boats.”

Notwithstanding their current ferocity, these are the very same seas we found ourselves in long before the pandemic. There have always been just as many of us with ill-fitting life jackets, just as many without one, and just as many who haven’t been taught how to swim. Yet the global nature of this crisis has forced existing entrenched inequalities into focus.

A defective system

There is growing recognition that diverse identities and social conditions shape an individual’s likelihood of becoming ill, receiving or being denied access to quality care, and dying or surviving. Yet health policies have tended to treat everyone the same.

The deadly consequences of this are all too tangible for the hundreds of thousands of women health care professionals with ill-fitting personal protective equipment that is designed for the average male body. Their lives are at increased risk simply for falling on the wrong side of a deep-rooted bias.

To understand this historical blind spot, we must consider patterns of where the decision-making power lies. “The Global Health 50/50 Report 2020” examined the gender-related policies and practices of the top 200 global health actors, from NGOs and private sector companies to government agencies and the United Nations system. Its findings expose a system embedded in long-standing power relations that trace back to colonialism.

According to the report, there are four times as many CEOs of global health organizations from high-income countries as from middle- and low-income countries, and over two times as many men as women, evidencing a skewed distribution of power in the current model. Once we apply an intersectionality lens — the framework through which we examine different manifestations of advantage and vulnerability based on intersecting characteristics such as sex, gender, race, class, ethnicity, age, ability, and sexuality — the distribution of power is even further distorted. Just 5% of CEOs in global health are women from middle- and low-income countries.

The report also observed a lacuna in organizational measures to mitigate these inequalities and diversify power. Just 44% of organizations included had policies to promote diversity and inclusion in the workplace with measures to back these commitments up, compared with 69% that had gender equality policies.

These findings reflect a broader trend in development policy. While gender mainstreaming has become relatively well established since its formal adoption at the 1995 Fourth World Conference on Women and the concept of intersectionality has become integrated into feminist research since its inception by Black feminist movements, there has been a bottleneck in uniting these developments and applying intersectional analyses to gender mainstreaming in development. For example, while we have seen a 45% decrease in maternal deaths worldwide since 1990, Black women in the U.K. are still five times more likely to die during childbirth than their white counterparts.

An opportunity to turn the tide

The momentum created by the circulation and consumption of information on the pandemic, and its inequitable outcomes, should prevent the public health community from turning a blind eye.

To mitigate health inequities, we must apply intersectional analysis to question the assumed neutrality of policymaking, starting with the following:

1. Diversity mainstreaming. The pace of progress in gender mainstreaming since the mid-1990s should be matched with an approach that more accurately reflects intersecting grounds of disadvantage.

Olena Hankivsky’s concept of “diversity mainstreaming” presents a radical reimagining of gender mainstreaming. It recognizes gender not as the primary axis of discrimination, but instead as reinforcing of and reinforced by other forms of oppression, demonstrating a more comprehensive understanding of lived experience.

Diversity mainstreaming in health policy would demonstrate a more comprehensive understanding of lived experience and increase accountability toward the diverse populations it serves.

2. The “politics of presence.” We know that diverse representation in positions of power improves substantive policy outcomes for a greater diversity of social groups. Yet “The Global Health 50/50 Report 2020” found that just 14% of organizations have policies in the public domain that detail how they will advance diversity in their governing bodies.

Long-term governance mechanisms that create transparent and equitable methods for recruiting professionals with varied backgrounds, while remaining mindful of tokenism, are imperative.

As a short-term solution, quotas can be utilized to promote diversity. An example is the South Africa-based nonprofit organization Sonke Gender Justice, which commits to 25% youth representation on its board with standing positions for sectors related to women’s advocacy, people living with HIV/AIDS, youths and children, and faith.

3. Disaggregating to evaluate. The profound change required to mitigate health inequities is impossible if these are not measured. Widespread collection of disaggregated data is essential. Yet in the current crisis, just 53 of 133 countries assessed by Global Health 5050 are publishing sex-disaggregated data on the number of COVID-19 cases and deaths, and just 25 countries further disaggregate this data by age.

One example of good practice is that of the Philippines Department of Health, which is publishing coronavirus case numbers disaggregated by sex, age, and geographical region, as well as death rates, hospitalizations, and intensive care unit admissions disaggregated by sex. Failing to collect and report disaggregated data should be recognized for what it is: a political choice.

The COVID-19 crisis has crystallized long-standing inequalities in people’s experience of health. Intersectionality is the solid ground on which to build an equitable and inclusive response to the current pandemic and achieve equitable access to health.

While uncertainties about the future of public health remain, we can say for sure that only intersectional solutions will erode the legacies of systemic oppression and inequality that leave some of us able to reach dry land and others drowning.