A global conversation on racism in public health

March 10, 2021 by Sahlah 'Kit' Dubel

PATH leaders share valuable perspectives, lived experiences, and hopes for the future of the sector.

Black History Month town hall screen capture

Clockwise from top left: Dr. Scott Gordon (USA), Dr. Caroline Phiri-Chibawe (Zambia), Dr. Nanthalile Mugala (Zambia), Sibusiso Hlatjwako (South Africa), Dr. Cyril Engmann (Ghana, USA, UK), and Sahlah ‘Kit’ Dubel (USA).

My name is Kit Dubel (bottom left in the image above). I am a project manager with PATH’s Center for Vaccine Innovation and Access and workstream lead for the Black PATH Employees Network.

In February, it was my honor to moderate a PATH employee town hall focused on the experience and impact of Black leaders in global public health. The panel included five of my esteemed PATH colleagues.

The following comments, questions, and answers are excerpted from the event.

Kit: As a Black woman working in global health, born in DC, and raised in inner-city Baltimore, Black History Month is extremely meaningful to me. We use this time to recognize the successes of our communities, and to study and learn from our history, not just with each other, but with everyone. We honor the energies of those who came before.

I, like many, am the descendant of both enslaved and free people. The voices of my ancestors are quieted, but the work of their hands still touch my life. While slavery as a trade and as a legal institution was ended many years ago, as a nation, we are still impacted by residual forces and systems that continue to challenge us to this very day—and I know the same is true for other countries.

Black History Month is a call for us to study our history—of Black Americans, of African diasporas, of many African cultures and communities and of Black communities around the world. And we do this, so that we can understand the history that has contributed to the identity of who we are today and consider what the path for our future should look like as we become what we hope to be as a collective human race.

Scott, could you speak to the moment we’re in right now from the American perspective? What feels most relevant to you?

Scott Gordon, ScD, MPH (Director, Malaria Vaccine Implementation Program): When I think about Black history, I also think about my own personal history and how it relates to the context of COVID-19 right now. I was born two weeks after the US Supreme Court overturned laws in 14 US states that made my parents’ marriage illegal because of their race.

So, this really is my history. And it’s important to stress that US laws like this weren’t just written on the books—they were written on the bodies, the minds, and the hearts of the people in this country, and they were reinforced by social systems. Those same social systems continue to exert major harms and major challenges on our society today. And we can see it borne out in the COVID-19 pandemic.

COVID-19, here in the US, continues to exert major harms on Black, Indigenous, and people of color communities. Harms that are really disproportionate to their population size. There are growing bodies of evidence that demonstrate that African Americans in the US are three times more likely to become sick from COVID-19, and three and half times more like to die from it; that both in the US and in the UK, just being Black or a person of color or an ethnic minority, is actually a significant risk factor in and of itself for becoming sick and dying of COVID-19—even controlling for other comorbidities.

Kit: Thank you, Scott. I’d also like to hear from Cyril and Sibu. Do either of you have thoughts about the moment we’re in right now, or its potential for the future?

Sibusiso Hlatjwako, MPH (Advocacy and Partnerships Manager, Advocacy and Public Policy): Thank you, Kit. I’ll go back to COVID-19 and what it’s shown. Right now, in Africa, we have a continent that is sitting and waiting for “simple” things like vaccines and other interventions that are produced on other continents. One of the opportunities I see for the future and that would give hope, is if the world could be very decisive about supporting the development of infrastructure like manufacturing capacity.

This is a space that PATH is already involved in, and those are the initiatives where I see a lot of hope for bridging inequality gaps and ensuring that countries and regions are self-sufficient in terms of meeting all the basic health needs of that country or region. That’s just one thing I’m hopeful for. It hasn’t happened yet, but the discussions have started. And that gives hope to moving humanity forward, to moving Black communities forward, toward health equity and health access.

Cyril Engmann, MD, FAAP (Senior Director, Quality and Program Impact): You know, what gives me hope is the fact that, it feels like for the first time we are really having a conversation, because we actually realize the scale of the problem. There were so many people in North America and in Europe who thought, there wasn’t actually a problem. That we were living in a post-racial situation. And there were so many people who, by extension thought, “Well, colonialism ended 30, 40, 50, 60 years ago… and we’re all equal now. The systems that we have are all equal.”

“For the first time, it feels like there’s a true understanding of the problem.”
— Cyril Engmann, MD, FAAP

But now, for the first time, it feels like there’s a true understanding of the problem, and now we’re doing the really hard work of actually trying to lean into the problem, and trying to understand: What is it? How are we going to characterize it? How are we going to understand the scale of it? And how pervasive is it?

And the challenge for us is not to just rush in and come up with some half-baked effort that isn’t sustainable or transformational, or to rush in without even understanding the problem, it’s to really lean in and say, “How can we do this in an authentic, transformative way that’s going to be long-lasting and not transactional?”

Kit: In our sector, we’ve seen the Black Lives Matter movement grow into a very active conversation about racism in medicine, and about decolonization as it relates to global health.

Caroline, what are your reflections on the moment we’re in right now? And looking to the future, how do you hope the current Black Lives Matter movement will shape science and public health?

Caroline Phiri-Chibawe, MD, MPH (Chief of Party, Program for the Advancement of Malaria Outcomes-Plus): With regard to racism right now, a lot of African countries gained independence more than 40 years ago. So, we don’t really deal much with racism within our countries—particularly in comparison with those who were recently under colonial influence and power. But we do deal with racism, especially from developed countries.

We have situations where we have prescriptive funds, strategies, and experts who come to manage our local challenges for us. We also deal with people at large global convenings—racism is still very much a reality in those contexts. We find that you have to speak out very loudly at these meetings to be heard and for your opinions to actually be respected.

“Let’s buy into local communities and homegrown solutions. Those are the solutions that should be supported.”
— Caroline Phiri-Chibawe, MD, MPH

As for the future and how we can shape science and public health, when we are managing our programs, let’s buy into local communities and homegrown solutions. Those are the solutions that should be supported. Sometimes they are, but frequently, they are not. When these entities that have lots of power and control over how the money flows are involved in the work, we find that our own health priorities are put aside and are replaced with donor priorities.

When I see the current momentum around diversity, equity, and inclusion, I see it as an opportunity for us to assess our own challenges, to grow our own solutions, and to have us in Africa influence the strategies, influence the interventions, and influence the global picture as well. If that is not done, we are affected. Our health is affected. And I am affected as a public health professional because it is very difficult to implement anything in such an environment.

Scott: I’d like to respond to Caroline’s point about colonialism. Colonialism and racism are both about power, and about the particularly toxic linkage of power and race. They’re also about how we assign value on the basis of assumptions that are really false.

If we look back at the last year and the Black Lives Matter movement a lot of that movement was really about calling out those systems and the false underlying assumptions that are conflating race and power and value. I think in a global context, as well as in a domestic context, it’s really critical for us to continue to call out those assumptions and challenge the systems that reinforce them.

Just like Caroline was illustrating in the context of these meetings and the work that they are doing in Zambia, think about the voices that we are listening to, ensuring we are giving voice to all communities, and unpacking the assumption that one community has greater value or greater power than it should.

This work has a lot of relevance to the Black Lives Matter movement because it’s about unpacking our assumptions and giving voices and equal weight to other communities. I’m actually really optimistic about the global movement right now, because it’s raising a lot of uncomfortable, but really critical discussions, looking at the intersection of power, race, and value. And I think that has a lot of bearing for PATH as an organization.

Kit: I want to note that many of our panelists have a background in maternal and child health. The difference in outcomes for Black women and their babies are well known.

Cyril, as a neonatologist, could you share how these disparities resonate with you?

Cyril: I’ll give an example in the US and the UK. The infant mortality rates for Black babies is double to triple that of white babies in the US and in the UK. But what I find most compelling, is a recent study published last summer examining infant mortality rates off 1.8 million newborns. The authors showed that Black babies were twice as likely to live when they were cared for by Black physicians, compared to when they were cared for by white physicians.

That’s stunning. And to me, it demonstrates the effects of bias that many of us see and experience—sometimes even on a daily basis—and sadly, even here at PATH. Whether overt or unconscious, these biases bleed into every aspect of our lives. And no one, not physicians or public health practitioners alike, are immune from these biases.

To me, what this study highlights is the importance of having a lived experience to the very survival of newborns. It highlights the need for more training for all races of physicians and public health practitioners, and the need for more accountability—individually and collectively. In the US at least, it also highlights the need to proactively increase the number of minority or Black physicians, health workers, and clinicians of all sorts. Currently about 14 percent of the US population is Black, but only about 7 percent of active US physicians are Black.

Having those lived experiences from the people and communities you are supporting is critical—not just in the US context, but in any context where populations experience disproportionately negative outcomes.

Kit: Nanthalile, how does the conversation about racism and colonialism resonate with you as PATH’s leader of the Africa Region?

Nanthalile Mugala, MD, MMed (Chief of the Africa Region): As PATH’s first-ever Chief of the Africa Region, and first-ever African-born and bred female Executive Team member, it’s important for me to state plainly that the roots of health inequity are fundamentally linked to the history of Black people. Colonialism, slavery, extraction, wealth inequality, everything that has been spoken about by our panel today.

“The roots of health inequity are fundamentally linked to the history of Black people.”
— Nanthalile Mugala, MD, MMed

The reorganization that took place within PATH last year, which distributes more decision-making power outside the United States, is the beginning of a journey—and I must emphasize, it is a journey—to putting us on equal footing with our headquarters. It is a major milestone, for me, for my colleagues in the Africa region, but also for the entire organization and for global health as a sector.

The conversations about racism, about colonialism in our sector and in public health, science, and medicine, are definitely making a difference. We heard from Cyril how important it is that we are able to sit around a table together and be very candid together in these conversations.

Kit: Caroline, how can we leverage homegrown solutions and innovative technology being produced by PATH?

Caroline: For any given health area, homegrown solutions are already part of the government system. These solutions have been integrated into a strategy the government is supporting and implementing.

What we need to do is to marry our technology and innovation to whatever the government is already doing. For us as PATH, that means finding ways to apply our advantages. And we do have advantages. We are quite innovative, we are good with devices, we are good with data management, and so on.

When we apply our technology to health facilities, to districts, even to the ministry of health itself—decision-makers can see their own solutions through a clearer lens with better data management and better data visualization. We shouldn’t be in the driving seat. We should be supporting the health sector during planning, when they are prioritizing and implementing and scaling up programs.

Usually, the government already knows what strategies it wants, they have tried these homegrown solutions, and they are most likely working. It’s best if we can harmonize our plans with what they are doing, apply our expertise in terms of the technology, and let the government actually lead in implementing.

Kit: Thank you for that, Caroline. You’ve all probably heard the slogan, “If you can see her, you can be her.” That’s not just attributable to “her.” I think that mantra speaks to a growing cry from our communities to see people of color in positions of influence and leadership across all professional areas.

As mentors, what message of encouragement would you give to those who are new to public health, or interested in joining public health?

Sibu: This is one time where the issues of change and race have really been in the forefront. And think my message is: opportunities are out there. As you say, “if you can see her, you can be her.” So, strive for your dream—work to get to the position you want to be in and to make the difference that you want to make. Be the change that you want. If you keep working on that, we will get to where we are going.

Caroline: For those who are just joining public health, what I’d advise is: learn your subject. Learn your subject quite well, and then don’t be scared to speak. You know your stuff, you know where you are coming from, you know your community, you know what they want. Don’t be scared to speak. Even if they don’t listen at first—one day they will listen. So be confident to speak. Reach out and express what you want. It really really helps, especially in the big meetings.

Scott: The piece of advice that I would offer is: see the value in your own lived experience. Your life experiences give you a perspective, an importance, and a weight that you can bring to your work. So, see the value in your own lived experience. And as Caroline said, use your voice to express that experience and bring that into conversations and bring that into your work.

Cyril: I’d say: show up, persevere, and be authentic. Continue to be your authentic self—but show up. By “show up” I mean turn up, be engaged, and be involved. By “persevere,” I mean… public health is not a one-shot race. There is no moon shot in public health. This is a lifetime endeavor—and so, persevere.