Men in Global Health, Time To 'Lean Out'

Privileged men from elite institutions in the global north call the shots in global health. If addressing inequities, especially in LMICs, is one of the central goals of global health, then men must find ways to lean out, and create space for women and diverse expertise.

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“Global health is plagued with vast asymmetry of power & privilege. We’re all part of a broken system. Doing good work in the field requires one to first understand this, taking a critical eye to one's own identity & how one has benefited from a system that oppresses so many others” - Dr Senait Fisseha

It's International Men's Day today, and I wanted to share some thoughts on men in global health. But, I must begin by acknowledging my own privilege. I am a cisgender, able-bodied, heterosexual male, highly educated, living in a high-income country (HIC), working as a tenured professor at a top-tier university. While I was born and raised in India, I completed my education in globally top-ranked universities. I am aware of my privilege, especially the privilege that comes from being a male in a male-dominated world.

Global health today is neither global nor diverse. There is good data to show that every aspect of global health is dominated by individuals, institutions and funders in high-income countries (HICs). The Global Health 50/50 report found that more than 70% of leaders in the sample of 200 global health organizations are men, more than 80% are nationals of HICs and more than 90% were educated in HICs. A typical CEO of a global health agency is 3-times more likely to be a male, 4-times more likely to be from a HIC, and 13-times more likely to have been educated in a HIC. Global health is delivered by women, but led by men (graphic, courtesy Women in Global Health).

Why does this matter? Well, if addressing inequities, especially in LMICs, is one of the central goals of global health, should we continue to entrust privileged men from elite HIC institutions to lead us towards that goal? Do they truly represent the people being served? Are they close enough to the problem? Are they close enough to the solution?

For any meaningful change to happen, folks in HICs, especially men, must find ways to spend or share their privilege. Change begins with individuals, but must then also extend to our institutions and global health structures.

Change at the individual level

For global health to become more equitable, diverse and less power-asymmetric, there is work to be done at the individual level (‘decolonizing’ ourselves) and at the structural or institutional level (‘decolonizing’ our institutions).

I think the first step is just waking up to the deep power imbalance in global health and understanding the origins and consequences of such power asymmetry. It's like being unplugged from The Matrix! Once we wake up and see the reality, it is hard to 'unsee' it.

We all need to educate ourselves, especially men. I have personally found it helpful to undergo structured, repetitive training in privilege, anti-oppression and allyship (here is one example). In fact, I think everyone in global health must be required to undergo such training. Being a male is a privilege and it offers massive unearned benefits in all walks of life, especially in global health and development.

Men, especially older, established men, can do many things to share their privilege and "lean out" to create space for younger people, women, and diverse voices.

I recently participated in a 'manel' on "The Art of Leaning Out: A Conversation about Male Allyship," at the Women Leaders in Global Health conference (you can watch the video below).

During this panel, we spoke about what men can do to lean out. I gave a few examples of what I am doing (or trying to do) in my own personal space:

1. I have stepped down from journal editorial boards and encouraged the journals to replace me with women from LMICs. Some journals have done this already.

2. When I get invited to give talks or write editorials or commentaries, I now decline many of them and suggest experts from LMICs, especially women experts.

3. When I write op-eds and invite experts to comment, I count to make sure I have gender balance & avoid citing only men; I also make sure I include quotes from experts in LMICs.

4. When invited to join panels and commissions or committees, I point out lack of gender balance at the start, and advocate for inclusion of experts from LMICs. I have organized two all-female panels (here is an example). Men, of course, should refuse to be on all-male panels as a policy.

5. When I write letters for women students or faculty, I now check the language to make sure I use stronger words to underscore their talents and productivity. This important for me, since a majority of my trainees and staff are women. Until recently, I was not aware of the gender bias in reference writing. Reading this wonderful guide opened my eyes: Avoiding gender bias in reference writing

6. When I teach courses, I check to make sure I have gender balance in faculty.

7. I have helped mentor women with their academic job searches and have supported them with salary & package negotiations. I have learnt that women are often hesitant to negotiate salaries and this is one driver of the gender pay gap that is seen in all areas of global health.

8. While I have mentored a large number of women trainees, it is only recently I learnt about the difference between mentorship and sponsorship. "While a mentor is someone who has knowledge and will share it with you, a sponsor is a person who has power and will use it for you (Herminia Ibarra)." I now understand that "women tend to be over-mentored and under-sponsored." I am now learning to become a better sponsor. This has made me publicly advocate for women to be selected for awards at my school.

It has taken me years to make these changes and I am fully aware that I have a long way to go. But it is possible to make changes at the personal level. In particular, older, established men can make these changes very easily, without any loss to their reputation or stature. In fact, their stature will grow, not diminish. The bigger challenge, I am finding, is in pushing for institutional change.

Change at the institutional level

This is much harder, since global health institutions lack diversity, and are dominated by men with privilege (see graphic below from Global Health 50/50 report). Changing leadership and board composition is not easy, since privileged men hate giving up power (the US elections are a good example!).

Global Health 50/50 Report

There is a growing movement to "decolonize global health" and this can certainly help bring change at the institutional level. The Black Lives Matter movement is critical to make sure Black women and people of color are represented at the leadership level. The growing Women in Global Health movement is another strong force for change. The Covid-19 pandemic is another potent driver of change - in 2020, we have also seen that women leaders have done a better job with the pandemic response than men, and HICs don't necessarily have all the answers and solutions. Hopefully, as these various movements and forces collide, this year will open the door for meaningful changes in how global health is structured and practiced.

As Ruth Whippman so eloquently wrote in her NYT article Enough Leaning In. Let’s Tell Men to Lean Out, we need to "Write the book that teaches men to sit back and listen and yield to others’ judgment. Teach them how to assess their own abilities realistically and modestly. Tell them to “lean out,” reflect and consider the needs of others rather than assertively restating their own."

It is clear to me that men in leadership roles have a critical role to play - in making sure leadership roles are more diverse, inclusive and gender-balanced. In short, men have to learn to become good allies in the struggle for gender equity. The big question is: will men think beyond personal gain and give up power? I don't know. But I do know from experience that change is possible.

Madhukar Pai

Associate Director, McGill International TB Centre

I am a Professor and a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. I serve as the Associate Director of the McGill International TB Centre. URL: http://www.paitbgroup.org/

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