COMMENTARY #MeToo Meets Global Health: A Call to Action

A Statement by Participants of the Global Health Fieldwork Ethics Workshop, April 2018

This statement arose from discussions during the Global Health Fieldwork Ethics Workshop held in Atlanta, Georgia, USA in April 2018, co-sponsored by Agnes Scott College, The Taskforce for Global Health, and Emory University Rollins School of Public Health. As participants from a wide range of academic and global health implementation organizations discussed ethics challenges in fieldwork settings, it became clear that gender-based violence was an issue of vast importance that has not been adequately considered for global health fieldworkers and participants. This statement highlights key themes on gender-based violence that emerged from our discussions and calls for further action. 

In many respects, global health is a women-centered enterprise. Women are often the local participants in global health programming, are growing in numbers as members of local implementation staff, and form a clear majority in the classrooms of public health educational institutions. Despite this deep engagement, women in global health—as in workplaces, fields of study, and societies across the globe—are not positioned as equals. Of course not. Gender bias shapes our norms and expectations for success and who will achieve it in global health, even as we fight collectively for equity in access to health care and other human rights issues around the globe. Further, as the #MeToo movement has begun to lay bare across employment sectors in the US and beyond, women in global health also experience sexual harassment, sexual assault, and other forms of gender-based violence, about which they are encouraged by institutional structures and processes to remain silent. For this culture of silence, we—the men, the women, the people, of global health—are all responsible. Gender-based violence in global health is not a women’s issue. It is an issue for all of us.

In this statement, we call for increased attention to sexual harassment, sexual assault, and gender-based violence of all forms across global health, from our training programs to research institutions to implementation organizations. Women and people of all gender identities and expressions have the right to safe workplaces, and we have the right to be acknowledged without judgement when our safety has been compromised.1 We call particular attention to women in contexts of “fieldwork,” where local norms may conflict with global health goals and operational practices. Though we choose inclusivity through use of the term “gender-based violence,” we foreground violence against women and the more subtle forms of discrimination women disproportionately experience.2 Our goals are to recognize the legacies and structures in global health that enable gender-based violence, highlight some of the challenges to women’s equality and safety in global health fieldwork, and point to steps forward in creating healthy work environments for all. Above all, we wish to encourage open dialogue and action to address gender-based violence within global health, where such violence has been an object of study but rarely an acknowledged reality for many who work in the field.

Gendered experiences of global health

While the paternalism of the colonialist roots of global health have been acknowledged, if not removed from our theoretical and operational paradigms, we have yet to fully reconcile how these antecedents to our contemporary work have shaped gender norms and biases within our field.3  The challenges particular to women go largely unacknowledged in the formal discourse of global health. Gender-based violence has become a vital area of global health study and programming in recognition of the terrible prevalence of gender-based violence; indeed, we know that 35% of the world’s women experience gender-based violence in their lifetimes.4 The United Nations has developed protocols for mitigating gender-based violence in contexts of humanitarian crises because of the increased vulnerability of women and girls for sexual violence and exploitation in these settings.5 The increased attention on the global health burden of gender-based violence over the past 30 years is an important and encouraging step toward health equity.6 However, the women who participate in global health—the program managers, fieldworkers,  researchers, local promoters, and community members—have not been appropriately acknowledged as susceptible to gender-based violence, potentially made more so through their global health engagement.

Within the university settings in which global health workers are trained in high-income countries, the large proportion of women enrolled as students (one leading institution reports up to 85% of undergraduate and 70% of graduate students interested in global health are women) would seem to indicate that these are no longer male-dominated spaces.7 However, we also see that women face greater challenges in attaining permanent academic positions, moving up the ranks of the academic hierarchy, and having their professional achievements recognized.8 In recent studies, women from across academic disciplines have described high rates of sexual harassment, discrimination, and assault. Among women in academic institutions, more than 50% of faculty and staff, and between 20% and 50% of students, report experiences of sexual harassment, impacting their professional, psychological, and physical health. This harassment is most likely to occur when women are trainees.9 Beyond the experience of sexual harassment, women in academic contexts are far more likely than men to report experiences of gender bias in academic settings and in professional advancement.10

Outside of the academy, women in global health face gender-based violence as they take up roles in implementation organizations, where incidents can occur both in the “field” and in “home” offices. As in academic settings, women are vastly underrepresented in global health leadership roles; only 25% of representatives in the World Health Assembly are women.11 Professional environments where women are not well-represented in leadership may be more likely to perpetuate workplace cultures where sexual harassment and barriers to successful reporting and responsive action are tolerated. Within global health institutions where people from diverse cultural backgrounds are brought together, instances of sexual harassment may be brushed aside as cross-cultural misunderstandings.

Prominent media coverage of sexual abuse within the humanitarian aid sector has highlighted the reality that global health workers can also be perpetrators of gender-based violence.12 Perpetrators of gender-based violence in global health and aid organizations can target women in local communities who are project recipients, as well as their colleagues.13 Global health institutions have a responsibility to consider that their employees and those engaged in their projects can be both the victims and perpetrators of gender-based violence, and the institutions must be able to provide appropriate support and disciplinary action. Following recent aid sector scandals, new guidance is emerging for reporting and accountability mechanisms.14

Relationships are at the center of global health projects, and the deep power dynamics embedded within those relationships impact our successes. Gender affects the ability to command respect and build rapport within professional relationships, and when gender-based violence enters into the work of global health, that work is indisputably compromised. Many global health workers enter the field due to a desire to “do good,” and the goal of helping others may make it more challenging for fieldworkers to report gender-based violence. When our work is to help achieve the right to health care for others, standing up for our own rights can feel antithetical to that purpose, and women may be reluctant to report instances of assault and abuse. However, the cost of helping others should not come at the hidden expense of personal health, safety, and career advancement due to gender-based violence.

Gender-based challenges in global health fieldwork

Women everywhere face gender-based violence, but women in global health fieldwork can be particularly at risk for sexual harassment, sexual assault, and other forms of gender-based violence. We define fieldwork broadly to mean activities undertaken to further global health research or program implementation by both local and foreign global health workers. The experiences of women in global health fieldwork are incredibly varied, both in the nature of their work and in the ways that they may experience gender-based violence. Yet, there are distinct challenges that global health fieldwork poses for women. A recent survey of field experiences across academic disciplines showed that 70%  of women experienced sexual harassment and 26% experienced sexual assault during fieldwork; the study further illustrated that fieldsites often lack relevant sexual harassment policies and codes of conduct that would be in place in traditional workplaces.15 Experiences of rape and attempted rape have been documented as significant issues for women anthropologists.16 The most substantive review of gender-based violence against public health fieldworkers was published two decades ago, and the issue of gender-based violence in global health fieldwork is vastly understudied.17

Women in global health are tacitly expected to follow fieldwork methods established by men, and women must work harder to live up to the unspoken standards of being “tough enough” to make it in the field. On top of the routine challenges of global health research or project implementation, women fieldworkers must invest incredible energy in ensuring their personal safety through: carefully monitoring their behavior and local perceptions of it, creating a personal appearance that cannot be construed as sexually provocative, and ensuring safe housing, often by needing to live within the context (and rules) of a local family.18 These tactics are context-specific, and they are more likely to be shared in the hallways outside of conference rooms rather than through training sessions held inside. Informal strategy-sharing is an important lifeline for many women in global health; for example, women regularly cut off or color their hair, wear baggy clothes, stay indoors after dark, and even wedge a rubber doorstop under their doors at night. The necessity of such (unacknowledged) steps in order to maintain safety and complete work is far more pronounced for women than for men.

Global health fieldworkers are trained to respect local norms and customs, yet adherence to those norms can shape and constrain opportunities for collecting data or implementing programs, particularly for women. Women, both local and foreign, must navigate gender norms within the fieldwork setting while sometimes explicitly flouting them to achieve global health project objectives. The disruption of gender norms inherently introduces risks for women, and foreign women are routinely particular objects of scrutiny in fieldwork settings. Though their status as foreigners may counterbalance their gender identity, affording them greater freedom and mobility than local women, women undertaking fieldwork abroad are often targets of gender-based violence. While some types of sexual harassment may be normative for the local context, it can be challenging for foreign women in the field to adjudicate what is “normal” and potentially to be ignored—some catcalls or invasions of personal space are perhaps to be expected—and what should be cause for concern, a change of strategy, or merit reporting. There is no clear line between an acceptable ordinary and an abusive extraordinary when it comes to sexual harassment and assault in a cross-cultural context. Indeed, in global health fieldwork, as in human rights, cultural relativism has limits. Women will have different personal views of what is comfortable or acceptable during participation in global health projects, but they should not have to make decisions about balancing their safety with project completion without the support of their institutions and colleagues. Cultural difference should not be invoked as a reason to dismiss or discount the concerns and negative experiences of women in the field.

#MeToo and implications for global health

The #MeToo movement has brought unprecedented attention to gender-based violence. #MeToo has had significant limitations in its representation of the experiences of all women and people of diverse gender identities, and it has been widely criticized for eliding the voices of women of color and prioritizing the experiences of a powerful elite.19 It has, however, unquestionably moved gender-based violence into mainstream public discourse. The #MeToo movement has been highlighted as an opportunity to frame sexual harassment as a public health issue and address it more holistically within the context of health promotion.20 It has not yet been meaningfully harnessed as an opportunity to improve the experiences of women in public health or global health, though emerging collectives such as Women in Global Health are encouraging. Some, but not all, of the professional organizations of disciplines contributing to global health have sexual harassment policies, and only the American Anthropological Association’s policy acknowledges that sexual harassment and assault may occur during fieldwork away from home institutions.21

#MeToo has marked an important shift in how gender-based violence is reported and counteracted. For so long, women who report gender-based violence have been disregarded or discredited. The stigma of gender-based violence means that these uninvited experiences become a woman’s defining identity, and their other work, achievements, and professional identities fade away.22 Some of the women who have described sexual assault and rape in the field have done so under pseudonyms.23 Reshma Jagsi, a clinician who has studied sexual harassment within medicine, has insightfully described her own unconscious efforts in reputation management when she realized she was quick to make the distinction that she has studied sexual harassment but not been a victim of it.24 The fear of damaged reputations and the stigma of being the object of gender-based violence are real. Women must be positioned as agents, not objects, of global health—able to take up global health roles from community participant to institutional leader without fear that their experiences will be dismissed or bar them from pursuing their goals.

Points of entry for addressing gender-based violence in fieldwork

Gender equity is a problem in global health, and the dangers of inequity become most clear in contexts of fieldwork. While no fieldwork is without risk, and many global health fieldwork sites are dangerous and carry substantial risks, we can take important steps to mitigate risk through appropriate training and institutional support. One danger in describing the gender-based discrimination and violence that women face during fieldwork is that they will be sidelined from such work. This is not what we suggest—far from it—nor do we suggest that paternalistic decisions should be made on when, where, and how women should engage in fieldwork. Open dialogue about the risks of gender-based violence during fieldwork can be an important starting point to enable appropriate preparation, decision-making, and support for women in the field. We also need to prioritize research on this vastly underreported and understudied issue.

Training

Within academic institutions, meaningful field-based training opportunities are often limited until much is at stake for a student’s future career success. While there is a great deal of variation in training strategies across the disciplines contributing to global health, students are often sent into the field either alone or to work with local supervisors in unfamiliar contexts. Global health students and trainees are particularly vulnerable to gender-based violence because they may be ill-prepared for the challenges they will encounter—in large part because those challenges often go unacknowledged in our training curricula. It is important for mentors and supervisors to raise awareness that gender-based violence can be a reality of fieldwork. Opportunities to prepare for potential challenges and develop strategies for addressing risks specific to the fieldwork context are of great value but are not uniformly available. Global health training insttitutions can take an important step in openly sharing training procedures, curricula, and lessons learned so that best practices can be developed across the field.

Open discussion would also dispel the notion that facing particular fieldwork challenges, including gender-based violence, undermines the legitimacy of research and the expertise of the fieldworker. Acknowledging our human susceptibilities in global health fieldwork can open new avenues for mentors and mentees, faculty and students, researchers and field implementation teams to share experiences of gender-based violence and other fieldwork challenges across gender and personal identities. The denial of susceptibilities in general and of gender-based violence in particular may stem from individual and institutional malaise that such topics are difficult to handle well, but this does not justify ignoring them. Deans of schools of public health, faculty mentors, and field supervisors must take up the responsibility to discuss gender-based violence in fieldwork and include it in their curricula for all students. Above all, attitudes and approaches that blame the victim must be removed from our peer, supervisory, and institutional relationships in global health; women can be well-prepared, do everything right, and still encounter gender-based violence.

Institutional support

Global health institutions must better balance the need to maintain positive reputations with the need to acknowledge and address gender-based violence. Appropriate preparation for global health workers entering the field is essential, but ongoing support and mechanisms for reporting gender-based violence are equally important. Training needs and methods may differ among government, non-governmental, and academic institutions, but all institutions have opportunities to devote explicit attention to the risks and challenges distinctive to women. Institutions should engage people of all genders in discussions of gender-based violence and trainings on how to recognize and report it within the specific institutional context and work setting. Institutions must also comply with legal responsibilities to students, employees, and clients and any liability they may incur through these relationships; yet legal obligations cannot serve as a proxy for an institutional commitment to equality. Some legal structures, such as Title IX for US higher education institutions, may prescribe protections for women but create limitations for individual decisions about disclosures of gender-based violence and options for institutional support. Institutions, therefore, should consider how to go beyond legal obligations to promote gender equality within their particular mission. They must work to disentangle the complex webs of organizational values, power, and gender that keep women sidelined from leadership roles. As the vanguard of the right to health, our field has the opportunity to lead a sea change in creating equitable and healthy working environments. 

Conclusion: Only the beginning

We call for an inclusive #MeTooGlobalHealth—not a moment, not a movement, but the modus operandi of global health. Simply, we should respect the contributions and experiences of all our colleagues and participants, and we must elevate gender-based violence until equity is no longer a sentiment but a reality. Words, no matter how strongly felt, cannot fix gender-based violence in global health workplaces, but our collective action can. We hope to create space within global health for others to speak for themselves and be acknowledged in solidarity and support. We believe in building action rooted in our shared experiences to improve prevention, recognition, and responses to gender-based violence in global health.25 Global health must apportion some of our emphases on equity and the rights to health and safe living and working conditions to ourselves, ensuring that these rights are attainable for those engaged in global health work, too.

We have committed to acknowledging and addressing gender-based violence in global health. We assert that gender equity is for everyone—and we should all contribute. To join us in solidarity with this statement, share resources and specific points for action, and add to the conversation, please visit: wetooglobalhealth.org.

Rachel Hall-Clifford, Agnes Scott College

David Addiss, The Task Force for Global Health

Peter Brown, Emory University

Arachu Castro, Tulane University

Mary Clisbee, Zanmi Lasante and Partners in Health

Robert Cook-Deegan, Arizona State University

Dabney P. Evans, Emory University

Arlan Fuller, Harvard University

Aubrey Graham, Emory University

Michelle Grek, Emory University

Deirdre Guthrie, University of Notre Dame

Olusimbo Ige, United Methodist Committee on Relief

Arthur Kleinman, Harvard University

Stephanie Larson, Emory University

James Lavery, Emory University

Deborah McFarland, Emory University

Dave Ross, The Task Force for Global Health

Adam Weiss, The Carter Center

Breanna Wodnik, Emory University

Christopher Woods, Duke University

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