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How we talk about public health and why it matters

November 11, 2020 by David Verga

Harmful power dynamics plague our sector. Better word choice is one small way communicators can help challenge them.

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As our understanding evolves, our language should evolve along with it. At PATH, that means changing the way we write about our work.

PATH has experts working on vaccines, medical devices, and dozens of other pursuits. But we also have communications experts thinking about words, about narratives, and about their importance in public health and global development. But why?

Is word choice really worth the handwringing? Do words have that much power?

Yes, it is. And yes, they do. As James Baldwin points out in Notes of a Native Son, “the root function of language is to control the universe by describing it.” Regardless of our intent, the words we use have material consequences.

When public health communicators (like us) broadcast messages across global platforms, when we advocate for policies or appeal to people or partners or fellow NGOs, the way we describe our work shapes the way others see it, and think about it, and act on it.

Countries, for example, are not monoliths, but that’s seldom apparent in public health communications nor in the media at large. In reality, the barriers to health equity vary so widely within every country on Earth, describing those barriers at national altitude is not only imprecise, it can actually be harmful because it encourages audiences to think of national populations as being homogenous.

Of course, some generalization is normal and necessary in mass communication—especially when unpacking technical topics. But often, it goes too far. To be on the lookout for potentially harmful generalizations, it’s helpful to consider when and where they are most likely to occur.

Hint: all communicators (myself included) are far more likely to make these mistakes when writing about a geography or community other than their own.

That’s why at PATH, we’re in the midst of a years-long globalization of our communications function, distributing even more of our comms positions to offices around the world.

And it’s why we’re constantly updating our brand standards. By using clearer, more precise language, we're able to communicate more ethically and more effectively.

Here are a few of the recent changes we’ve made to our standards, and a brief explanation of the reasoning behind them.

1. “Beneficiary”

We no longer use “beneficiary” to describe the people, communities, and countries with whom we work. In fact, we stopped using the term “beneficiary” a few years ago, but it’s still so common in our sector and in the media that it takes the #1 spot on our list.

At first glance, the term can seem neutral, which may account for its broad usage. But “beneficiary” patronizes those it describes in a few key ways: it defines a person, community, or country in terms of support received; it removes agency and implies dependency and passivity; and it fails to provide any context as to why the inequity or disparity in question exists in the first place.

Perhaps most damaging of all, “beneficiary” suggests that organizations are deciding who deserves some “benefit”—as though health isn’t already a human right. (It is a human right.) For more accurate, effective, and ethical alternatives, PATH prefers referring to people, communities, countries, clients, partners, or end users.

2. "Developing country"

Like “beneficiary,” we began phasing out “developing country” several years ago, but it’s worth revisiting why. To do so, we must go back further to the “developing country’s” predecessor: the “Third World country.”

As a term, “Third World” grew out of the Cold War to describe nations not aligned with the East (Communist Bloc) or West (NATO). Because this category included most countries in Africa, Asia, Latin America, and Oceania, the term grew in use within the global health and development sector and became a euphemism for other descriptions like “poor” or “non-white.”

Then, in the late 1990s, the term “developing country” arrived with the Human Development Index, a mathematical model that combines life expectancy, education, and income to rank countries according to their “level of development.”

Even in its original context, this word choice is problematic. Describing a country as “developing” implies that it is, by definition, “incomplete.” Despite its problems, “developing country” was silently adopted as the preferred sector terminology and is still widely used today.

The newest iteration—the “low- and middle-income country” or “LMIC”—is itself an adaptation of World Bank country and lending groups, which define countries as having “low-,” “middle-,” or “high-income economies” according to gross national income per capita.

Within the context of banking, “low-,” “middle-,” or “high-income economy” may be a relevant and appropriate term, but broadened into “low-,” “middle-,” and “high-income country” for use in global public health, several issues immediately arise.

First, as already noted, discussing health challenges at the national level is imprecise and, depending on the context, potentially harmful.

Second, “LMIC” frames health challenges in terms of economics, but we know health disparities don’t exist exclusively along those lines. They exist along lines of race and gender as well, and when we talk about it in terms of economics, we erase other root causes that need to be addressed.

Stephanie Kimou, Georgetown professor and founder of PopWorks Africa, suggests saying it plainly: “formerly colonized countries.” This term attributes disparities to the oppressive structures and practices that created them rather than the current deficit(s) people are facing as a result.

Though PATH is not adopting "formerly colonized countries" as an all-up replacement for "LMIC," we are adding it to our vocabulary for use when historically relevant and contextually appropriate (and working to reduce our use of "LMIC" at the same time). In most cases, however, we're simply trying to be more specific.

3. "On the ground" or "in the field"

We are phasing out here vs. there phrases like “on the ground” or “in the field.”

There’s nothing inherently wrong with prepositional phrases, and we recognize the public health definition of “fieldwork” as simply denoting “getting out of an office and into a community.” However, in the broader context of global public health and development, these particular phrases reinforce harmful and pervasive power dynamics in a few key ways.

They suggest that PATH parachutes into the communities and countries in which we work—whether from the United States to Kenya, or from Nairobi to Kisumu. This is simply not the case. Though PATH does have three offices in the United States, 60 percent of our staff are in Africa and Asia, and 95 percent of our global team are from the places where we work.

Here vs. there phrases also paint a picture of global public health as something that takes place in rural communities on dirt roads. Some of it does, including in high-income countries like the United States. But 55 percent of all human beings live in urban areas. By 2050 it will be 68 percent. The only time we are “in the field” is when we’re supporting dairy farmers with bovine estrus tests to improve the timing (and so, the success rate) of insemination. Otherwise we work in communities, laboratories, and offices all over planet Earth.

4. “Empower”

For the past several years, “empower” has seemed a constant refrain of nonprofits and NGOs. And for good reason—inequities are symptoms of power imbalance.

However, we find in our own writing—and the writing of other nonprofits—that the word has become badly overused. It seems that everything our sector does has been reframed as one form of empowerment or another. But what actually empowers?

People can empower themselves through advocacy. Policies can empower people. Gaining representation in government can empower people. What do these things have in common? They’re all examples of structural authority codified by a group of people.

At PATH, we’ve come to the conclusion that empowerment is something that occurs across groups and within shared structures. With this understanding, we’ve been shifting many of our uses of the word “empower” to more specific verbs like “equip,” “inform,” “educate,” or “train.”

In addition to being more precise, these words also avoid the harmful power dynamic of one group bestowing power upon another. It may seem like minutiae, but these nuanced linguistic questions keep PATH communicators up at night.

5. “At risk” or “vulnerable”

Like “empower,” we will still occasionally use the terms “at risk” or “vulnerable,” but we are striving to be far more specific in our usage.

Within a public health context, it is accurate and appropriate to say that immunocompromised populations are especially “vulnerable” to an infectious disease outbreak or that a group may be put “at risk” by researchers through errors or mistreatment.

However, these terms become problematic when they are used as general descriptions of populations or communities, or used as euphemisms for poor communities, communities of color, communities in particular geographies, etc. This is a disrespectful and over-generalized way to describe a group of people.

In each of these cases, the specific context provides the framework needed for the term to be used accurately and appropriately. Using these terms more broadly, or with inadequate context, suggests personal weakness or helplessness on the part of those being described rather than drawing attention to the systemic reasons the vulnerability exists in the first place.

At PATH, we’ve decided that these and similar terms should only be used in complete context. If we cannot name precisely what people are at risk of, vulnerable to, marginalized by, etc., we just won’t use those words.

Instead, we’re trying to drill down to the level of specificity required to describe what we should be getting at anyway—specific barriers to health equity in the specific communities in which we work.

To our fellow communicators
We don’t have all the answers and we know we’re far behind. Activists, anthropologists, community organizers, and others aren’t learning these things from us—we’re learning from them. We just want to make sure we’re failing in the right direction in our corner of the world. If you’re a public health communicator, we'd love to hear from you. How has your language changed over the years? And how did you reach those decisions?

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