Ethics of Global Health Photography: A Focus on Being More Human

Volume 21/1, June 2019, pp 49 – 62


Aubrey P. Graham, James V. Lavery, and Robert Cook-Deegan


This article explores the relationship between ethics and the production of global health photographic images. Through the text, we emphasize the need for greater awareness of potential ethical pitfalls, not just in relationship to the finished product of the image but also throughout the full photographic process. In order to do so, we present and explore three vignettes detailing our personal global health photographic experiences. Using these examples of the process of photographic production, we argue that the ethical emphasis needs to fall as much on the way of making and circulating the images as on the resulting images and their content. In showing that ethics starts long before the decision to publish a photograph, we engage global health photography as a relationship built of unequal power dynamics, where agency is held (albeit lopsidedly) by all of those around the camera—the subject, the photographer, and the bystanders or actors who exist beyond the photograph’s composition. By following the concept of “encouraging people to do what is best given certain circumstances and constraints,” we as photographers and global health workers advocate for a more fully human interaction through conscious, careful global health visual policy and humane photographic deliberation.[1]


For decades, photographs have played a central role in the documentation of global health issues, outbreaks, crises, and successes. While expected as part of the visual economy of global health research and representation, photographic images nonetheless hold the power to leave a mark on both the individuals photographed and those who take the photos. In this article, we explore the ethics of global health photography by addressing poignant instances of image production that are grounded in our personal experiences as photographers, as well as academics and practitioners. Further, we aim to show the need for greater awareness of ethical pitfalls, not just in the image but throughout the photographic process and its uses.

Using detailed vignettes, we address our personal experiences with the ethical dilemmas brought home when creating images in global health and human rights fieldwork. While we produced our respective photographs in different crises at different times, each retelling elicits insights borne of hindsight. With awareness comes a desire to better understand both the ethical quandaries of the images and our personal, affective responses to the photographic situations. In our vignettes, we raise questions that stretch beyond the subject matter of the image itself. Instead of leveling our critique only at such representational content—the signifiers and their meanings captured within the frame of the image—we also raise ethical concerns about the process of global health photographic production and its uses. Engaging these vignettes in the order they occurred, we address our actions and the relationships implicated within photographic creation, publication, and dissemination. In so doing, we advocate for global health visual policy and conscious photographic deliberation for a more fully human interaction beginning before the shutter snaps and carrying forward throughout the life of the image.

Global health photography

We define global health photography as taking and using images in the service of a global health program or initiative. Images may range from professional photographs created by contracted photographers to cell phone images crafted by agency staff and visitors. In this article, we discuss photographs produced in the context of chemical weapons use, displacement, genocide, conflict, and maternal health. Our images, like many human rights and humanitarian photographs, were not created haphazardly. Rather, they follow a system that employs the image as both evidence of reality on the ground and a means of organizational marketing.[2] Such images are not only persuasive beyond words, but are used to supplement words, often to elicit emotional reactions. Such photographs populate newsletters, websites, news stories, social media, communication campaigns, letters to donors, political advocacy, and public presentations. In each type of communication, global health images fulfill their roles through the power to multitask, merging emotional resonance and documentary accounting; they graphically witness the nature and scope of human needs, account for money spent and work completed, and play central roles in crafting campaigns for support, targeting the government, donors, or the general public.[3]

Images produced in the service of global health and human rights are guided by an often implicit visual economy. Deborah Poole describes the “visual economy” as the way images are understood in relation to the relevant “social relations, inequalities, power relations and politics,” which require attention not just to a photograph’s content but also to the process of its production, circulation, and consumption of images.[4] She argues that images function as cascades of flows that, like the economy, follow a system shaped by the globally implicated exchange values and visual economy of the image and its genre.[5] Thus, as images are created, circulated, and consumed, they get incorporated into the international power dynamics embodied in the relationships of photographer, subject, consumer, and publisher.

Within the economy of global health imagery, the benchmark currency is a “good” or “necessary” photograph—one that is both legible and functional for the organization. There is often an expectation that surrounds both the representational content and the expected work the images will perform. Poole shows that while such images rarely come with explicit viewing instructions, the photographer’s act of creating the image responds to, and conforms to, all of the previous circulations and consumptions of similar images—a learned awareness of the moment and of what makes a potential photograph “valuable” and therefore worth capturing.[6]

In large part, since the 1970s, “valuable” images within the visual economy of humanitarianism and global health have been those that are able to incite action through moral outrage or, more recently, through a shared sense of empowerment. In particular, the notable visual tropes of skeletal adults, fly-eyed children, white saviors, and the dead haunted publications from the late 20th century aiming to raise the compassion, awareness, and funds necessary for intervention.[7] As these photographs circulated in international news media and advocacy campaigns for nongovernmental organizations (NGOs), they also drew criticism for how they objectify, demean, and “further reduce the powerlessness” of the featured individuals and groups.[8] Kevin Carter’s 1994 Pulitzer Prize-winning photograph of a Sudanese child and a lurking vulture presents a quintessential example. Was the trade-off between momentary objectification and the potential of further funding, attention, and action a worthy one? Arthur Kleinman and Joan Kleinman provide a related call to action, noting:

We will have to engage the more ominous aspects of globalization, such as the commercialization of suffering, the commodification of experiences of atrocity and abuse, and the pornographic uses of degradation … the first issue would seem to be to develop historical, ethnographic, and narrative studies that provide a more powerful understanding of the cultural processes through which the global regime of disordered capitalism alters the connections between collective experience and subjectivity.[9]

This article aims to do just that. The ethical challenges that motivate these visual critiques share much in common with the ethical challenges that have fueled the growing emphasis on participatory practices, community and stakeholder engagement, and co-production of knowledge in global health.[10] Like photography, these approaches and emphasis on ethical action are not new, though they do represent challenges to the status quo. Within global health, the weight placed on ethics has long been understood to be a key factor in not only what research is conducted but also how it is carried out. The 1979 Belmont Report, National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, for instance, provides an early example of essential guidelines surrounding the need for beneficence, respect, and justice in global health research. Over the past four decades, ethics has come to occupy a central place within global health as the collective consciousness is raised about the presumptuousness, disregard, unfair partnerships, exploitation of power differences, and even human rights violations that continue to occur in the context of global health programs.

Returning to the photographs—while the critiques are excellent at drawing attention to the photographers’ composition, little exists in print about the actions, decisions, and negotiations that lead to the production of the global health images, ethically questionable or not. We hope that by focusing retrospectively on the actions, thoughts, and insight from photographer-practitioners in situations of uncertain ethical action, we can incite better understanding of how ethics are implicated throughout the process of creating images. In other words, by tying the growing importance of global health ethics into the existing critiques and ethical concerns about photography produced in the practice of humanitarianism and global health, we argue that some critical self-reflection on the practice of photography might serve as an excellent point of departure for a broader engagement with these problems in global health programs.

Photographic retrospectives

In the following vignettes, we engage three distinctive images and their respective social politics and ethics. Our first two retellings (vignettes by Cook-Deegan and Lavery, respectively) function to outline ethical challenges implicit within the production phase of the visual economy of global health images. Through the third vignette (by Graham), we grapple with similar visual quandaries and logistical challenges, but also work to produce a path forward toward increasingly ethically aware photography. In each of the vignettes, we look back at photographic production and the relationships that the act of photography forges through each snap of the shutter.

Pictures and poison gas: Vignette by Robert Cook-Deegan

Despite years of work in health and human rights, I had never heard of the Kurds until September 1988, when Jonathan Fine and Susannah Sirkin called from Physicians for Human Rights (PHR) in Cambridge, Massachusetts. After a month of trying to get a team into Iran, they had decided to instead send a team to southeastern Turkey to investigate the alleged chemical weapon attacks that had occurred the previous month against the Kurds of northern Iraq. The world knew the attacks provoked a flood of refugees from Iraq into Iran and Turkey. Refugees were now in camps along Turkey’s borders with Syria and Iraq. The advantage of Turkey? No visa was required.

That phone call launched a frenzy of research. I was employed at the congressional Office of Technology Assessment, with full access to the resources of the Library of Congress and a Rolodex of contacts in national organizations and federal offices. I spent that weekend reading The Poisonous Cloud, a history of chemical weapons by Fritz Haber’s son, and collected the 252 reports from the United Nations (UN) about chemical weapons use in the Iran-Iraq War that had ended in 1988.[11] That war consumed eight horrible years that left well-nigh a million dead and severely wounded, but very little change in the national borders or political balance of power. It was a stupid, wasted war that entailed the most extensive use of chemical weapons since World War I. It was the most flagrant violation of the 1925 Geneva Protocol prohibiting the use of chemical weapons since the protocol entered into force in 1928.

The UN reports left no doubt that chemical weapons were used.[12] The question in the fall of 1988 was whether and how Saddam Hussein’s Iraqi government used chemical weapons against its own civilian Kurdish population. The March 1988 chemical attack on the city of Halabja drew international attention. The attacks against the Kurds in northern Iraq five months later, and the flood of refugees into Iran and Turkey, produced a flurry of news reports, but the governments of Iraq and Turkey denied permission for a UN ground crew to investigate, and despite extensive intelligence corroborating the attacks (made apparent years later), the major powers—including the United States—equivocated about whether the attacks had even occurred.[13]

PHR mission to southeast Turkey

Enter PHR to fill this gap. A team of three—Asfandiar Shukri, a Kurdish-speaking Detroit physician; Howard Hu, then a young faculty member at the Harvard Medical School; and I—assembled various materials in preparation for a 10-day investigative field mission. One of the most useful documents was a how-to report from the government of Canada, entitled Handbook for the Investigation of Allegations of the Use of Chemical or Biological Weapons.[14] It warned that direct access to the sites of attack might be blocked. It included a questionnaire to elicit details to document an attack and identify the chemical agents involved. Dr. Shukri translated this questionnaire into Kurdish, and we took more than 100 copies with us.

After preliminary meetings, we gained access to two refugee camps near Diyarbakir: one camp in Mardin, along the Syrian border, and another just outside Diyarbakir itself. Turkish authorities running the camps introduced us to Kurdish leaders in the camps. We explained that we were American doctors who wanted to know the health status of those in the camps. Dr. Shukri conducted interviews inside one large tent, while camp residents filled out questionnaires. I was the videographer for those interviews, while Dr. Hu circulated throughout the camp doing field epidemiology.

The questionnaires proved to be important sources of evidence, because we could triangulate responses from residents of the two camps who had not had contact with one another but who originated from the same villages, which would allow us to independently corroborate accounts. We also took photos of healing chemical burns. But the most useful artifacts of the camp visits—the evidence that proved most persuasive—were pictures of the refugees, especially the children and women, and videotapes of Dr. Shukri’s interviews. The persuasive power of women and children was not merely emotive but also evidentiary: they were not combatants, but civilians caught in poison gas attacks.

The testimony of one eight-year-old girl, in particular, was utterly compelling. She had been silent for weeks in the camp, in shock from having lost both parents and several siblings to the poison gas attacks. She had been out tending the sheep a kilometer uphill from her home when bombs fell near her house, killing half her family. She returned to find them dying and turning color, with froth leaking from their mouths. She was restrained from touching them by relatives, who then led her and other surviving children on a several-day trek across the mountains into Turkey. Dr. Shukri somehow made her feel safe enough to tell her story. She did so in a soft, calm voice, often quavering; there was not a dry eye among the 20-some listeners in the tent. Indeed, the video footage was shaky, as I trembled from uncontrollable emotion.

We prepared a preliminary report of our findings that was released before we left Ankara and worked on a more complete draft on the flights to Frankfurt and Washington. Upon our arrival, we briefed members of the House Appropriations Committee and officials in the State Department, and held several press briefings. We wrote our report, Winds of Death, in November and December. The draft report was sent for external expert review in January and the final report released in early February; a summary was published in the Journal of the American Medical Association.[15] Over the next six months, I testified a half-dozen times in the House and Senate, as our evidence was deemed relevant to the 1989 Iraqi sanctions bills that passed overwhelmingly in Congress but were ultimately pocket-vetoed by President George Herbert Walker Bush because he did not want the precedent of Congress intervening in foreign policy.[16] This was one of several diplomatic missteps that the US government made, which Saddam Hussein interpreted as a green light to invade Kuwait in August 1990, which in turn led to the First Gulf War of 1991 (and another PHR mission to southeast Turkey and northern Iraq in April 1991).[17] We also gave many presentations to NGOs and government organizations—including human rights organizations, foreign policy groups, and those concerned about the use of chemical and biological weapons. Those briefings featured our video and photographic evidence, which was the most compelling aspect of our story and much more gripping than the quantitative data. The eight-year-old girl was literally our poster child for an advocacy campaign.

We did take precautions to protect our materials. While in the field, I kept the videotapes on my body at all times. We knew that if we were detained while I was carrying the tapes, we would be giving authorities the most damning evidence and would lose our most valuable material. We surmised, however, that the authorities were unlikely to escalate to the point of detaining and searching us. We were quite careful to protect the completed surveys from prying eyes. I left a blank set of surveys in my briefcase in our hotel, deliberately leaving my briefcase in our locked hotel room. My briefcase was opened while we were at dinner, as was Dr. Shukri’s suitcase—which held the video camera in which we had placed blank tapes (see Hall-Clifford and Cook-Deegan in this volume). We thus confirmed that someone was curious about our activities. We redoubled our attention to confidentiality. But once we returned to the United States, we encouraged the broad use of our materials. Our purpose was, after all, to get the word out, to confirm the poison gas attacks against civilians in northern Iraq, and to dispel doubts that such an attack had happened at all.

We thought through our use of photos and videos mainly in retrospect. The visual materials were very widely distributed and could have led authorities back to the camp residents whom we interviewed. While of relatively low quality, excerpts of our videotapes were used by US broadcast and cable networks because there were no better sources. Longer excerpts were incorporated into a UK documentary, Winds of Death, on UK Channel 4, where they were widely viewed.[18] A copy of our report was found in the possession of an Iraqi journalist who ventured into Iraq. He was arrested and executed in the prelude to the 1991 Gulf War, and we learned of his death from UK journalists. The low-resolution photos in our report were thus clearly in possession of Iraqi authorities. In looking back, we realized we had endangered those we photographed and videotaped. The story could have had an unhappy ending.

One of the striking features of this mission is how much effort was put into preparing to gather the epidemiological and survey data, as well as getting consent to gather survey data, and how comparatively little we thought about the photographs and videotapes. And yet those proved to be the most useful results of our work, and the sources of greatest risk to those we interviewed. The photographs in the PHR report were probably not identifiable, due to low-quality reproduction in those days of primitive laser printers and low-budget PHR reports. However, we used much higher-resolution photographs in public presentations to large audiences, including open fora in Washington, DC, that were no doubt attended by officials of the offending powers. There were well over 100 people present in one Senate hearing presided over by Senators Edward Kennedy and Jesse Helms, for example. We made no attempt to obscure the identities of those photographed. Through those photographs, people we spoke to in the camps were identifiable. While we had explained why we were in the camp, and it was obvious we were taking photos and recording videotape, we only later realized that we could have put those we interviewed in real danger. They were in camps for many more months, under the thumb of a demonstrably racist regional governor who had ordered the torture and death of hundreds of Kurds in Diyarbakir, as documented by Amnesty International.[19] While the interviewees and their families were aware of what we were doing in the camp, they simply could not have understood or anticipated the worldwide distribution of their faces and stories, any more than Pashtun refugee Sharbat Gula could have known that she would become one of the most recognized faces in the history of photography through Steve McCurry’s cover photo for National Geographic in June 1985.[20] Some of those in the camps might still have consented in the face of personal risk; but we put them and others at risk without their fully informed consent—not because we were unaware of the concept, but because we did not apply the precautions we took for written surveys to photographs and video interviews. One of our team remains in contact with the family we interviewed, and we know they are safe and reside in a part of Iraq that the government cannot readily touch, but we did not think through those risks in advance.

The power of the child’s photograph was directly attributable to her beauty and obvious innocence. We deliberately used it for emotive effect, and with no apologies for that effect. We were accurately documenting the story of a heinous crime via a first-person witness. Telling her story was voluntary, and the telling was greeted with relief by her family, a sign of psychological improvement after weeks of shock. But we could easily have mitigated the risks by being more selective in our audiences (for example, using high-resolution photographs only in personal briefings with members and staff, but not public presentations), and we could have ensured that the family was safe before using the photos publicly through the indirect channels of communication that persisted after our return. We recognized this mortifying lapse only in retrospect. The main lesson was to think through use of photos and videos as explicitly as other more traditional empirical evidence.

The primordial discourse: Vignette by James V. Lavery

The photograph that has prompted this narrative was the very first photograph I ever took in the context of a global health program, in this case a Médecins Sans Frontières (MSF) mission in Rwanda about nine months before the 1994 genocide. As the inaugural editor of Outskirts, the newsletter for the newly created MSF Canada, I was in Rwanda with Ben Chapman, MSF Canada’s program manager, to visit Pierre La Plante, a Canadian nurse who was leading an MSF mission to support Rwandan populations that had been driven south into various makeshift camps by conflict around the northern border with Uganda. We had arrived in Kigali, the Rwandan capital, on an overnight flight from Paris the previous day and had met the MSF team and settled into our rooms in the house that MSF was renting in the city. This trip was my first to sub-Saharan Africa. I had travelled in South Asia and North Africa previously and was an enthusiastic amateur photographer.

As the newest member of the MSF family at the time, MSF Canada was finding its way under the guidance of MSF Holland, our MSF parent-sponsor. As an inexperienced editor, I was beginning to learn about the importance of the MSF national newsletter as a fundraising vehicle, as a means of informing donors about how their contributions were being used, and as a way to serve one of the core elements of MSF’s mission: témoinage, or bearing witness to the humanitarian crises that are MSF’s raison d’etre. With these considerations front of mind, I was anxious to get into the field to begin my education about how MSF missions work and attempt to explain this to our Canadian readers through stories and the transportational power of photographs.

I was up early the following morning and pulled my cameras out onto the kitchen table. My Nikon F3 was already loaded with a roll of Fujichrome 100 slide film, and I loaded a new roll of Kodak Ektachrome 160 slide film into my Nikon FM2. I checked and cleaned my lenses, packed my camera bag and my notebook—the old paper kind—and was ready to go. We left for the field at 8:00 a.m. in the MSF Toyota Land Cruiser with our driver, Jean, who was later killed in the massacre. It was raining lightly and the sky was heavy in a state somewhere between mist and fog. I sat in the rear right-hand seat beside Ben and directly behind Pierre. We were headed to a large camp of about 40,000 displaced people about 90 minutes north of Kigali. But Pierre announced that he first had to make a quick stop at a smaller camp about 20 minutes outside the capital to relay a message to one of the camp coordinators.

The camp was easily accessible from the main road, and we pulled into a flat, open space about 100 yards in front of a collection of approximately 500 low, domed white tents extending up to the foot of the hill behind. The right side of the Land Cruiser was facing the camp, and as we came to a stop, a young man with a clipboard emerged from a makeshift plywood structure that appeared to be serving as some sort of office for the camp and came to greet Pierre. I lowered my window and felt the rain and dampness. My camera bag was open beside me with both cameras still inside. Even before we came to a stop, a small crowd of young men and boys approached the vehicle and—since Pierre was occupied with his conversation at the front window—started to assemble around my window, which at this point was completely open. As with many things in photography, the rest of the story unfolded quite literally in a matter of seconds. Pierre’s conversation turned out to be nothing more than the confirmation of a later meeting, which he wanted to do in person because of ongoing difficulties with communications with the camp. It lasted all of 60 seconds.

In the backseat, I was confronted with my very first photographer’s dilemma. At my window, just inches away from me, now stood four young men and behind them a small assembly of other young men and boys. Even before I had time to read the tone of the small crowd, I felt the tension. I was a white man sitting comfortably dry in a Land Cruiser, and they were wet and in profound need; their disappointment and resignation to the fact that I had nothing to offer them was immediately palpable. As this instantaneous processing was taking place, I had my moment of realization. I was here to document this. My cameras were at my side. It felt wrong, immediately. But maybe this is what serious photographers have to deal with every day. I turned to my left and grabbed my FM2, which was mounted with a 24 mm wide-angle lens. I turned back to the window and lifted the camera. A quick framing. A quick focus. And I shot a single frame. I lowered the camera, met the eyes of the young man directly in front of me, felt horrible, and said nothing. Mercifully, from my selfish perspective, Pierre’s task was complete and we began to roll out of the camp. I rolled up my window, dried my camera, and sat in silence. My very first experience of sub-Saharan Africa, my first experience of real human beings who had been displaced by conflict, and my first real experience of an ethically fraught photographic transaction, all behind me in less than two minutes.

Back in 1993, there was no preview button on our cameras. I finished shooting that roll of Ektachrome that day and bagged it for processing when we got home, along with the other 59 rolls of film I shot during the rest of the trip. It was more than a month later, when I picked up the slides from Benjamin Film Labs in Toronto, that I first saw the image I had captured. I had a small, cheap, battery-powered slide viewer at home and wouldn’t see the image properly projected for another week. But even in the 3×2 inch viewer, the image was stunning. The wide-angle frame covered the full width of the Land Cruiser window, with four faces in the foreground, peering in across the frame. In the background, the mist and heavy sky created atmospheric perspective for the hills in the background, with a few tents visible between the faces. There was a small “office” structure in the mid-background behind the faces to the left, an assortment of faces peering through gaps between the front row of faces, a black umbrella visible at the horizon line, and a hand reaching high in a slightly blurred waving motion between the central faces. The central focus of the photograph is a tall young man, slightly offset to the left of the image, his face framed by the waving hand on the one side and the small office structure on the other. He is wearing a sodden and drooping lemon-yellow loose-knit cotton sweater over a brown T-shirt. His arms are crossed, but only his right hand is visible in the frame across his left arm. A drop of rainwater dangles from his left earlobe like a gleaming miniature pearl earring­- an uncanny point of light that pierces the image.

But what makes the image stunning is this young man’s expression. It is no exaggeration to say it has haunted me from the moment I first saw the photograph. His eyes are piercing and angry. He is confronting me. He has seen my like before. He is not disappointed that I am useless in the face of his need—more incredulous and perhaps even disgusted that my instinct in response to this impromptu encounter is to reach for my camera. He is telling me that I have failed to even acknowledge him and his companions as human beings. In the moment, I had decided to treat them as objects for my camera and my readers. Even though I was a master’s student in bioethics at the University of Toronto at the time, he understood the ethics in this moment far better than I did. I had come, like so many before me, to take something from him and his community. I had not brought food, or dry clothes, or an umbrella, or even tea or water. I had come to prosecute my personal agenda, which was remote from his immediate needs, and his expression called me out in a way that was as potent and comprehensive as a Supreme Court decision.

In a speech to the Centers for Disease Control and Prevention staff while he was director in 1984, Dr. Bill Foege said that “if we are to maintain the reputation this institution now enjoys, it will be because in everything we do, behind everything we say, as the basis for every program decision we make, we will be willing to see faces.”[21] And in his book Alterity and Transcendence, Emmanuel Levinas talks about the ethical significance of encountering the faces of others. He argues that our institutions and politics that are purportedly designed in the pursuit of justice have lost their anchor in obligations to others. He argues that they have succeeded “in making us conceive of the particularity of the human being as negligible and as if it were not that of a uniqueness, but of an anonymous individuality.”[22] Elsewhere, in Totality and Infinity, Levinas says that “the face opens the primordial discourse whose first word is obligation” and, later, that “the face presents itself, and demands justice.”[23] I am indebted to my colleague Dr. Janet Parsons for introducing me to Levinas’s concern with the face. Although I became aware of these ideas many years after I took the photograph described above, they have helped me understand why this photograph has had such a profound effect on me, without a doubt one of the defining experiences that led me to my current career in global health ethics. Levinas’s point about the face demanding justice helped me grasp that in the brief moment of that encounter, the expression of the young man who presented his face to me, and captured me squarely in his gaze, reflected the full dark history of failure by people like me to view him as a fully realized human being and to take up his invitation to feel some sort of obligation in light of the extreme peril of his circumstances. Instead of responding in kind by, at the very least, offering my face in a gesture of human acknowledgement, I presented him with my camera. And I literally captured him in a convenient reduction that I could take back to Canada with me and use at my discretion, for my purposes.

I have never published the photograph. And I am all but certain that the young man in my photograph, and all the others who crowded the frame, were killed in the massacre in 1994. In a better world, I would have had the opportunity to share the photograph with him and to offer him my gratitude for the extraordinary education he has given me.

The necessary photograph: Vignette by Aubrey P. Graham

I enter the global health scene from the angle of a consultant photographer for humanitarian agencies. After finishing my anthropology dissertation research about the politics of humanitarian photography, I continued to shoot occasional “gigs” for aid agencies and global health organizations across the Democratic Republic of the Congo (DRC). Such consulting opportunities grew from a visual method I employed during my 2013–2014 fieldwork: “direct photography,” or photographing for the agencies into the realities of their fieldwork, gaining the ability to see the world through their advocacy-based lenses while encountering their processes and constraints. These experiences of producing aid photography led me to encounter the ethical decisions involved not just in the selection of images for NGOs’ publications but also the decisions central to the daily processes of creating the aid images.

In 2015, the eastern DRC continued to endure the ravages of two international wars—the First Congo War (1996–1997) and Second Congo War (1997–2002)—and the instability they created. North and South Kivu’s major cities of Goma, Beni, Butembo, and Bukavu regularly oscillated between periods of conflict and moments of metastable insecurity and back again. Yet the region as a whole was nonetheless plagued by chronic instability—there were more than 50 active rebel groups across North and South Kivu that harassed the population with forced recruitment, the threat and intermittent reality of attack, and the blocking of major arteries for moving goods and people to and from urban economic hubs. Within this context, infrastructural decay, chronically poor health services, disease, and diminished economic opportunities further challenged the region’s population and increased the need for and reliance upon humanitarian aid from both international and national NGOs.

In Goma itself—a city I knew well and whose dominant languages (French and Swahili) I spoke—I, as a consultant, could move about independently when photographing for agencies based in the region. At the time, I had my own motorcycle and could ride out to the internally displaced persons camp, the youth centers, the hospitals, or the in-city humanitarian programs and work at my own pace. On the first day of an assignment, this luxury of time allowed me to conduct the required meetings with staff and nod to the official hierarchy, tour the grounds with them, and take no photographs. Then I could return (sometimes frequently) to check in and spend time speaking with the agency participants and beneficiaries to understand the role that the NGO played in their lives. This meant that sometimes I would spend full days with them, often sharing meals, and gaining greater understandings of the depth and complexity of the situations and individual lives. Such processes led to meaningful relationships, on the one hand, and more creative, evocative photography on the other. Creativity, community, and freedom worked in synergy.

While working in Goma, I often would forget what a luxury that time was until I would accompany agency photographers out of the city on field visits or be shuttled out there under the supervision of the organizations to document their projects. In such cases, once the acronym-encrusted 4×4 would slow to a stop and the red dust cloud that followed it subsided, the NGO team would descend. Spreading out over the project site, the small group typically had less than an hour to get everything accomplished: assess the situation, check in with local management, and create the necessary images to then move to the next site. Assess. Confer. Document. Move on. Repeat.

It was in the process of conducting a slew of photographic success stories in the northern reaches of North Kivu Province with an agency (that I’ll call INGOX) that the ethics of the very process of photography came sharply into focus.[24] In 2015, I found myself in the town of Kamango on a short-term consulting contract (together with a Congolese videographer) with INGOX that operated in and around spaces of regional conflict. INGOX aimed to support its local partner NGOs. In this case, I acted as part of its media team, intending to create success stories for the smaller partner organizations that would be hosted on the INGOX website and aimed in part at its donor base.

“In here,” said the program lead for a Congolese NGO as he swiftly pushed a maternity ward door open without a knock. “This one [he pointed as he entered], she gave birth last night. Not a complicated birth, but her first one.” As sunlight, the program director, and my camera-toting-self filled the door frame, a young woman grasped for a sheet to cover her bare breast and her previously asleep child. The program manager looked back and forth from me to the woman. I remember thinking that I could nearly hear his toes tapping in impatience. It was clear that he needed me to depress the camera’s shutter so we could move on—so we could head over to the next ward, the next clinic, and the next set of photographs. With only a few scheduled hours of media-team time to cover multiple locations, efficiency took precedence over depth. My concern with the young woman’s awareness of the goals of the project stood in the way of his opportunity to frame a successful birth and move on. As the on-site program manager, he needed professional images that would transform their underfunded maternal health project into visually compelling stories intended to satisfy international donors and keep the door to further funding open. His lack of explanation and right of brusque entry made it clear that neither the young woman’s nor my own comfort with the situation were his primary concern. He simply needed the necessary photographs created in the limited time allotted.

By this time in my photographic career, I had learned to steal time and slow down the process. Swapping between Kiswahili and French, I introduced myself to the young woman, explained who I was, who I was consulting with, and laid out what the potential photographs would be used for, should she consent to having her photograph taken. The program director looked on in irritation. While he never left the small room, she relaxed and explained that she would be happy to contribute her image to the program as they had helped her deliver her firstborn child. As we spoke more about her experience in the clinic—with prenatal care, and about her decision to walk in the day before—I depressed the shutter and worked slowly to capture to her story and craft images celebrating her successful birth within the agency-funded maternity ward. The image that was in the end published by the international umbrella agency framed her laying carefully covered, her left arm acting as a pillow for her head while she beamed diagonally down at her child laying just below the level of her chin on the single-sized mattress. The image aims to show her healthy, happy, and seemingly grateful for the ability to give birth outside of her home in a space staffed by knowledgeable medical staff. That “necessary image” for that site could be checked off the list.

In the process of creating this and similar photographs, I became increasingly aware of the complex ethical implications of the visual process. At first, the issue of time—or rather, the lack of it—came to the fore. With it arose the issue of respect for and consent of the photographic subject. In comparison to the quantity of time—and therefore care—that I could take on my own schedule in Goma, when in the field with various programs and agencies, time was a valuable commodity. The umbrella or international agencies were responsible for paying per diems, hotel fares, flights, and associated travel expenses for media personnel. The longer these personnel stayed in the field, the more it cost.

As I reflected further on this experience, however, I came to recognize the power dynamics represented in the very bodies of those involved. A grown man in a position of organizational power entered the room in order to provide my camera and body entry. In relation to the gendered dynamics of the eastern Congo and of the NGO itself, the man’s presence demanded access and unquestioned consent. The prone new mother was in no literal or figurative position to resist or raise questions. Then I entered. As a foreign female carrying a camera whose images would flow back to Western countries, when my body passed through the doorway of that small maternity room, I did so implicitly embodying a position of extraordinary authority. I held the unexpected power of my race, foreignness, passport, and, perhaps most saliently at the time, the ability to produce authoritative images that would inform donors and INGOX of the potential success of the local maternity program and act as affect-laden documentation in requests for further funding. My presence brought her and her child’s body, their representations, and the struggles of the local NGO crashing into a global set of flows, meanings, and expectations.

The quotidian processes and constraints of photography—the assignment topics, the compact schedules, dynamics of gender and privilege, language barriers, involvement of program managers and staff whose jobs relied on positive representations, etc.—pepper an ethical minefield in which power dynamics, consent, and accuracy are often swept out of view in the pursuit of what one could call the “necessary photograph”—the photograph that justifies, the photograph that has the potential to do the necessary work of documenting, witnessing, and, ultimately, driving funding. In this space, it seems as much the responsibility of the photographer—in this case, me—as well as program managers, field staff, and the media team to slow down in the pursuit of more equitable visual engagement.

Ethics and global health imagery

Photographing global health images implicates fieldworkers in situations in which differences in power, gender, language, and economics can make it easy for photographers to exploit their subjects and their subjects’ circumstances for their personal satisfaction, or for their potential value in the global health visual economy. Situated within that important tension, we argue from hindsight that ethics, while not a perfect or guarantee-able system, must reside more at the forefront of one’s mind as one creates the photographic assignment, creates the image, and chooses what to publish. It is the ethics that shapes relationships and can therefore humanize the momentary connections that happen before, during, and after the point at which a camera punctuates an interaction and freezes time and content for later consumption.

Global health ethics, according to Andrew Pinto and Ross Upshur’s aptly titled An Introduction to Global Health Ethics, is a normative project that includes “both avoiding the enormous risks of doing harm and encouraging individuals to do what is best given a particular set of circumstances and constraints.”[25] Ethical responsibility, in this view, extends beyond the health work itself to the logistical and relational aspects of the programs, including the production and use of photographs to meet the demands of global health’s visual economy. As Cook-Deegan’s vignette illustrates, by the time a photograph has reached its published form, the ability of the photographer or the organization to avoid doing harm or to encourage what is right with respect to the treatment of the subject(s) is virtually nil. The drive to create images that are powerful may in fact, as in Lavery’s and Graham’s respective vignettes, lead to an ethical trade-off between the opportunity cost to the photographer and organization of not taking the photograph at all and the potential value of the image within the global health visual economy.

This is not to say that there have not been positive strides in the field of human rights and global health images in recent decades. Out of the rank suffering of the Global South photographed and published in the 1980s and 1990s came ethical codes of conduct surrounding the publication of image content, as well as individualized photo and media policies for global health agencies.[26] The Code of Conduct on Images and Messages—drawn up by the European NGO Confederation for Relief and Development (CONCORD)—has made important strides in reducing harmful image content and promoting dignified photographs of agency participants and beneficiaries. They note that “accordingly, in all our communications and where practical and reasonable within the need to reflect reality, we strive to: Choose images and related messages based on values of respect equality, solidarity and justice … Avoid images and messages that potentially stereotype, sensationalize or discriminate against people, situations or places.”[27] And while these guidelines are essential in promoting equitable and ethical depictions of situations, by the time these photographs are seen by other people—by the time they are ready to be “chosen”—it’s already too late for real ethical engagement. Rather, we’re advocating for a switch in the ethics to emphasize the ethical importance of the process of the production of photographs, not solely more judiciousness in the use of photographs that have already been taken.


Ethics has a place in assessing the representational content of the image. But it also ought to remain in the forefront throughout the entire photographic process—informing, in particular, which images to take, how to take them, and where those images later travel. While our retellings and analysis recognize the importance of what is signified in the image, we expand beyond addressing image content alone to bring our experiences as photographers into the scope of ethical concerns. We recognize the challenge of capturing a compelling photograph in the space of complex international relations and dire local conditions. We show how the reflex to photograph can, in ways, preclude the humanness of an encounter, shielding the photographer from the subject and creating a response that, while compelling, lacks the striving for equity that lies at the center of global health. Further, our photographs—and emotional reactions they produce—speak to both the very need for the image and the desire for it to capture what will literally “work” for the agencies that commission their production.

In showing that ethics starts long before the choice to publish a photograph, we engage global health photography as a relationship. Moreover, it is a relationship built of unequal power dynamics, where agency is held (albeit lopsidedly) by all of those around the camera—the subject, the photographer, and the bystanders or actors who exist beyond the photograph’s composition. By following the concept of “encouraging people to do what is best given certain circumstances and constraints,” we as photographers and global health workers call for action to craft slower, more intentional, better informed, human, humane relationships across the body of the camera.[28]

Drawing from our vignettes, such hindsight compels us to think about how to improve in the future. How can we channel these experiences to help educate younger generations of global health field workers and photographers about the ethical implications that are inherent in the process of photography? Doing so requires an understanding that each image arises from a set of momentary, fragmented relationships embedded in asymmetrical power relations and that the act of clicking the shutter bonds the photographer to the circumstances and ethics of the image’s production and begins the ethical journey of determining its appropriate use. Perhaps a desired outcome could be that rather than responding with the photograph as a reflex, or asking, “Is this a good global health photograph?” or “Will this image work for X agency?,” we might also ask, “Is this an ethical engagement that will equally produce an ethical image?” In so doing on an international scale, it is possible to imagine that we as global health workers and image producers could shift the genre’s visual priorities and reshape not only the visual economy of global health images but ultimately the very act of photography in the field. Perhaps, then, photography-based interactions could go beyond securing the “necessary photograph” aimed at witnessing, documenting, and advertising, to rather crafting photographs that are, at each encounter in their process, shaped by care and focused on a more equitable, human interaction across the lens.

Aubrey P. Graham is the Interdisciplinary Postdoctoral Teaching Fellow at the Institute for the Liberal Arts at Emory University, Atlanta, USA, and a freelance photographer.

James V. Lavery is the Conrad N. Hilton Chair in Global Health Ethics, professor in the Hubert Department of Global Health in the Rollins School of Public Health, and faculty member of the Center for Ethics, Emory University, Atlanta, USA.

Robert Cook-Deegan is a professor at the School for the Future of Innovation in Society at Arizona State University, USA.

Please address correspondence to Aubrey Graham. Email:

Competing interests: None declared.

Copyright © 2019 Graham, Lavery, and Cook-Deegan. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.


[1].   A. Pinto and R. Upshur, “Introduction,” in A. Pinto and R. Upshur (eds), An introduction to global health ethics (Abingdon: Routledge, 2013).

[2].   L. Chouliaraki, “Post-humanitarianism: Humanitarian communication beyond a politics of pity,” International Journal of Cultural Studies 13/2 (2010), pp. 107–126; H. Fehrenbach and D. Rodongo (eds), Humanitarian photography (Cambridge: Cambridge University Press, 2015); A. Graham, “Take this picture”: Humanitarianism and the politics of photography in the eastern Democratic Republic of the Congo, dissertation, Emory University (2016).

[3].   M. Givoni, “Beyond the Humanitarian/political divide: Witnessing and the making of humanitarian ethics,” Journal of Human Rights 10/1 (2011), pp. 55–75; M. Givoni, “Humanitarian governance and ethical cultivation: Médecins sans Frontières and the advent of the expert-witness,” Millennium-Journal of International Studies 40/1 (2011), pp. 43–63; Fehrenbach and Rodongo (see note 2); Graham (2016, see note 2).

[4].   D. Poole, Vision, race, and modernity: A visual economy of the Andean image world (Princeton: Princeton University Press, 1997), p. 8.

[5].   Ibid. pp. 8, 12.

[6].   Ibid.

[7].   A. Kleinman and J. Kleinman, “The appeal of experience; the dismay of images: Cultural appropriations of suffering in our times,” Daedalus 125/1 (1996), pp. 1–23; S. Moeller, Compassion fatigue: How the media sell disease, famine, war and death (London: Routledge, 1999); S. Sontag, Regarding the pain of others (Paris: Diogène, 2003); D. Campbell, “The iconography of famine,” in G. Batchen, M. Gidley, N. K. Miller, and J. Prosser (eds), Picturing atrocity: Photography in crisis (London: Reaktion, 2012), pp. 79–92; G. Batchen, M. Gidley, N. K. Miller, and J. Prosser, Picturing atrocity: Photography in crisis (London: Reaktion, 2012).

[8].   Sontag (see note 7), p. 78.

[9].   Kleinman and Kleinman (see note 7), p. 19.

[10]. J. V. Lavery, P. O. Tinadana, T. W. Scott, et al., “Towards a framework for community engagement in global health research,” Trends in Parasitology 26/6 (2010), pp. 279–283.

[11]. L. Haber, The poisonous cloud: Chemical warfare in the First World War (New York: Clarendon Press, 1986).

[12]. P. Dunn, “The chemical war: Journey to Iran,” NBC Defense and Technology International Journal (April 1986), pp. 28–37; Physicians for Human Rights, Winds of death: Iraq’s use of poison gas against its Kurdish population (Cambridge, MA: Physicians for Human Rights, 1989), pp. 37–38.

[13]. J. Ali, “Chemical weapons and the Iran-Iraq War: A case study in noncompliance,” Nonproliferation Review 8/1 (2001), pp. 43–58.

[14]. Government of Canada, Handbook for the investigation of allegations of the use of chemical or biological weapons (Ottawa: Government of Canada, 1985).

[15]. Physicians for Human Rights (see note 12); H. Hu, R. Cook-Deegan, and A. Shukri, “The use of chemical weapons: Conducting an investigation using survey epidemiology,” JAMA: Journal of the American Medical Association 262/5 (1989), pp. 640–643.

[16]. 101st Congress: S. 8, S. 195, S. 238; H.R. 696, H.R. 3033, H.R. 4585, H.R. 4653, and H.R. 5431.

[17]. R. H. Sandler, P. R. Epstein, R. M. Cook-Deegan, and A. Shukri, “Initial medical assessment of Kurdish refugees in the Turkey-Iraq border region,” JAMA: Journal of the American Medical Association 266/5 (1991), pp. 638–640.

[18]. G. Roberts, “Winds of death,” in G. Roberts (dir), Dispatches, UK Channel 4 television (1988).

[19]. Amnesty International, “In Turkish prisons: A report from Amnesty International,” New York Review of Books (1985).

[20]. S. McCurry, photograph of Sharbat Gula accompanying “Along Afghanistan’s War-Torn Frontier,” by Debra Denker, National Geographic Magazine 167 (June 1985)and accompanying C. Newman, “A Life Revealed,” National Geogrpahic 201 (April 4, 2002).

[21]. D. Addiss, “Global elimination of lymphatic filariasis: A ‘mass uprising of compassion’,” PLoS Neglected Tropical Diseases 7/8 (2013).

[22]. E. Levinas, Alterity and transcendence (New York: Columbia University Press, 1999), p. 176.

[23]. E. Levinas, Totality and Infinity (New York: Springer Publishing, 1991), pp. 207, 294.

[24]. For further detail on this particular aid mission and the issues of conflict and image making, see A. Graham, “Covering emergency: NGO photographs of stability in a space of ongoing conflict,” in C. Ndaliko and S. Anderson (eds), Art of emergency: Aesthetics and aid in African crises (Oxford: University Press, forthcoming).

[25]. Pinto and Upshur (see note 1), p. 11.

[26]. L. Malkki, “Speechless emissaries: Refugees, humanitarianism, and dehistoricization,” Cultural Anthropology 11/3 (1996), pp. 377–404; K. Manzo, “Imaging humanitarianism: NGO identity and the iconography of childhood,” Antipode 40/4 (2018), pp. 632–657; Batchen et al. (see note 7).

[27]. CONCORD, Code of conduct on images and messages (2012). Available at

[28]. Pinto and Upshur (see note 1), p. 11.