This post was originally published in 2018. I presented similar themes at the RCEM conference in November 2023. This blog highlights my point from the talk and updates the data, which sadly has not shown the progress that we would like to see since then.
I admit I cried during the movie Wonder Woman. I found the scene where Diana helps to liberate the villagers quite overwhelming; I still do. I cried not because it was particularly well choreographed or acted (although I think it was all those things too). It was because it reminded me of the wonder women in my life: my mum, my wife, my daughter; of what they could be, but also of what they couldn’t be at the same time. I cried because I wished the scenes where Diana barged through no-man’s land, flipped a tank on its roof and soared through a church tower were real. But of course it wasn’t. This made me sad.
With around 8.1 billion passengers along for the ride, spaceship earth is a pretty packed place. But unlike the Titanic there are no lifeboats to preferentially board if this ship goes down. Of course that doesn’t stop us from establishing a boarding priority through building walls, creating twitter bots, or rearranging the deckchairs to assert our superiority over one another. And why shouldn’t we? Just consider the state of healthcare on this ship. With around 11-13 million doctors, 30 million nurses or midwifes as well as 15-20 million hospital beds on board (you do the math), I need some guarantees that I can get to the front of this queue should I fall ill or get injured.
But hold on to your seats, it gets worse. The average global take-home wage for those on board with earning potential is just over £18,700 per annum, around 70-85% of us don’t have a fixed broadband internet connection and just over half have no access to the internet in any way or form (good luck submitting those academic manuscripts or catching up on The Witcher).
And to top it off, we are rapidly en route to missing most of the UN’s sustainable development goals: at current progress, the world will not eradicate poverty, end world hunger or provide quality education by 2030, it will take 300 years to attain gender equality, and we will overshoot the Paris agreement’s 1.5 °C.
Now, if these statistics seem foreign to you, then it is probable that you are one of the 16.7% amongst us, privileged enough to make it onto a lifeboat if there were any (but honestly there aren’t). For the rest of us however, these numbers will play an all too familiar tune – perhaps those of us who often endure bias as a result of personal demographics that we have no control over (such as where we were born, our gender, race or sexual orientation).
You see, there are only two kinds of people on this earth, those who acknowledge that the reason only 17 women have been awarded a Nobel Prize in science since 1901 (and no black people) are due (at least in some part) to prejudice, and those that don’t. And although the latter group is quite small, they are ironically also often privileged enough to just happen to be at the front of the boarding queue. The reason behind this of course is that when privilege is confronted with equality it often feels a lot like oppression. And when oppressed, we often feel the need to assert our position, in this case the right to privilege. Like me.
Growing up ignorant
I grew up in South Africa during apartheid. I recall living in a white-only neighbourhood, attending a white-only school and going on white-only holidays. Our maid once went on holiday with us, and I recall we dropped her off at a different beach. I figured this was merely because all her friends were there. I’m ashamed to say it didn’t occur to me for a second (until years later) that it wasn’t that at all; she simply wasn’t allowed on the beach we were heading to as she wasn’t flesh coloured enough (like my light beige colouring pencil).
Her daughter was about the same age as I. And when I went to medical school she went into nursing. It was nice to see her every now and again when our paths crossed at the hospital; we knew each other as children. But sadly she contracted HIV and tuberculosis during a time when our president couldn’t stomach providing anti-retrovirals to the public sector. As she was unable to afford treatment privately, she died. What struck me at the time was that the same healthcare system I was training to be a part of, failed to provide the care that would have been accessible to me, or anyone else in a position of privilege, if I fell ill with a similar illness.
Where be emergency care?
You may be surprised (or not) to learn that emergency medicine is a largely unknown specialty globally. There are only 24 emergency medicine journals (out of 102) published outside of the West; Africa only has one journal and Latin-America doesn’t have any. Ironically there are more patients in these regions that would benefit from primary research in emergency medicine than in any part of the West: more than 75% of cardiovascular-related deaths, more than 85% of sepsis-related deaths and more than 93% of RTC-related deaths occurs in low- and middle-income countries. And yet, despite low- and middle-income countries making up 83% of the globe, most of us are hardly aware of it.
How do I know this? Well, around two thirds of the most cited global, emergency care research are published in a format that is inaccessible to anyone without a subscription (and so not available for knowledge translation). Less than a third of research from high-income countries are open access (in contrast to up to 75% of research from low- and middle-income countries). Open access fees are often so costly that a third of African emergency care research is not even accessible in Africa. I have already mentioned the issue surrounding internet access earlier.
Now think of the cost of the last conference you went to. For someone coming from a low- or middle-income country, that cost will multiply by about two to four times due to the effects of a weak currency. And so, even at international conferences, delegates and speakers almost never represent the make-up of the international population. We are only just getting to grips with gender equality at conferences. Most of us will remember a time when men spoke on women’s behalf at these gatherings (or everywhere else for that matter). It is much the same when it comes to global health issues. The 83% do have a voice, many of us just choose to look the other way.
I know I did at least half my life.
It’s not a thing
In the end, we are all on the same space ship. And there are no lifeboats. Annet Alenyo in her 2017 SMACC talk spoke about Ubuntu, or the philosophy of togetherness. Annet pointed out that we are more similar than we are different and that we can only be strong together if we are strong individually too. I think it’s fair to say, that right now all of us are not strong.
Equality isn’t a thing and neither is global health. Equality and global health are things that each and every one of us can contribute to everyday. Every day we get to choose how much we will contribute. Choose how we identify and interact with gender, race and sexual orientation differences in our daily work. Choose how inclusive or exclusive we are when it comes to research, academia and collaboration. In other words, choose to make us all stronger together; and in the process become woke.
I for one, choose a world that will provide equally to my mum, my wife, my daughter, our maid, her daughter and all my African, Asian and Latin American colleagues as it would to me. Nothing less, nothing more.
And that, in a nutshell, is where global health starts. I would like to invite you to seek out your own global health journey, so that we may all be strong together.
Postscript: If you are struggling to digest this post and wondering how you can start your journey, may I suggest talking to someone of a different gender, race or sexual orientation about the challenges they face surrounding equality. When you read/ write a paper, ask yourself how the findings will apply in low- or middle-income settings, and if the paper would be accessible there. When asked to speak at a conference (especially an international conference), ask whether there are sponsorship options available for delegates from LMICs. And soon you’ll find yourself an avid global health advocate.
Editors note: This post supported the global health plenary Stevan coordinated at the EuSEM conference in Glasgow in 2018. He will touch on very similar themes at the 2023 RCEM Annual Scientific Conference, also in Glasgow. If you’re attending please come along and learn more about the challenges of inequalities in health and healthcare.
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(Post updated 09/2023)