Systemic racism in global health: a personal reflection
Authors: Bolajoko O Olusanya
Journal: The Lancet Global Health (2021)

Racism, colonialism, and White supremacy are synonymous terms for the pervasive injustice towards Black people that has attracted unprecedented public attention after the US police killings of George Floyd and Breonna Taylor in 2020. The surge of public emotions and anger was arguably ignited by the vivid exposure of this endemic societal evil. Leading medical journals and institutions have also pledged to take action against racism in global health.1The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 2Morse M Loscalzo J Creating real change at academic medical centers - how social movements can be timely catalysts.N Engl J Med. 2020; 383: 199-201Crossref PubMed Scopus (14) Google Scholar, 3NatureSystemic racism: science must listen, learn and change.Nature. 2020; 582: 147Crossref PubMed Scopus (12) Google Scholar The aftermath of Floyd's death caused me to reflect on my own experiences with discrimination in my various engagements in global health as a Black African woman with a congenital disability. I sensed that revealing systemic prejudice and holding the perpetrators accountable might at least slow down, if not completely eradicate, this disease—a type of social Buruli ulcer. And if healing must truly take place, victims of racism or discrimination must be emboldened to expose the ulcer bed, albeit through a painful debridement process. The recent call for readers of The Lancet Global Health to share their experiences is a step in the right direction.1The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar My active engagement in global health started in 2005, when I called for the inclusion of child disability statistics in the State of the World's Children report, published annually by UNICEF.4Olusanya BO State of the world's children: life beyond survival.Arch Dis Child. 2005; 90: 317-318Crossref PubMed Scopus (19) Google Scholar This was prompted by the apparent lack of consideration for the growing beneficiaries of the child survival revolution that began in 1982, that had been further bolstered by the Millennium Development Goals 2000–15. It was an ethical and moral call to ensure that child survivors with disabilities in developing countries were served with a global programme on early childhood development as a priority. In 2007, I witnessed the launch of the first Lancet series on early childhood development at my alma mater, the Institute of Child Health, University College London (London, UK), which became the foundation of the current Nurturing Care Framework for early childhood development.5WHOUNICEFthe World Bank GroupNurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. World Health Organization, Geneva2018https://www.who.int/maternal_child_adolescent/child/nurturing-care-framework/en/Date accessed: February 26, 2021Google Scholar This series estimated that 200 million children younger than 5 years in developing countries (updated to 250 million in 2016) were at risk of not realising their developmental potential, based solely on stunting and extreme poverty. During the question-and-answer session, I enquired why children with disabilities were excluded from the early childhood development series, and what plans were in place to recognise the disproportionately greater developmental challenges faced by these children compared with their stunted peers or children living in poverty. The explanation was that global estimates of children younger than 5 years with disabilities were not available. This exclusion implied that children with disabilities did not deserve priority consideration by policy makers. The two follow-up Lancet series on early childhood development, in 2011 and 2016, still did not address this research gap. In 2015, the UN Sustainable Development Goals offered some hope that discrimination based on sex, race, disability, and geographical location will no longer be condoned in global health. This encouraged a formal submission to WHO in January, 2018, through my UN accredited civil society organisation, in response to an open call for contributions on the draft Nurturing Care Framework. Strategies for addressing specific scientific, ethical, and moral concerns, and the necessity of such strategies, were all presented from the perspective of a developmental paediatrician based in sub-Saharan Africa—the region with the highest prevalence of children at risk of suboptimal development. Strangely, the submission, and similar recommendations in the literature at the time, were ignored. When another open consultation on a draft Nurturing Care Handbook was announced in January, 2021, like the earlier version and related journal publications, the list of authors and contributors was dominated by officials of both WHO and UNICEF, and their non-Black collaborators.6Olusanya BO Mallewa M Ogbo FA Beyond pledges: academic journals in high-income countries can do more to decolonize global health.BMJ Glob Health. 2021; 6e006200Crossref PubMed Scopus (6) Google Scholar The core team was glaringly racially imbalanced, with no named Black contributors from Africa, the diaspora, or within the entire UN system. Yet, pictures of Black Africans were displayed on the cover pages of the document to convey their misfortune and adversity, a practice that regrettably seems to appeal to philanthropists in high-income countries. More disturbing, was the preferential selection of White South Africans over Black academics ostensibly to represent sub-Saharan Africa. Additionally, the best available estimates of children younger than 5 years with developmental disabilities published in leading global health journals from 2018, were sidelined, reinforcing a common suspicion of the lack of commitment to truly support this vulnerable and marginalised population.7Global Research on Developmental Disabilities CollaboratorsDevelopmental disabilities among children younger than 5 years in 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Glob Health. 2018; 6: e1100-e1121Summary Full Text Full Text PDF PubMed Scopus (161) Google Scholar I still ponder why, even with the groundswell Black Lives Matter movement since 2020, researchers and policy makers in global health continue to eschew ethos of equity, equality, diversity, and inclusion. What is wrong with White and Black people working together for a global health agenda to serve all populations? Can these global health institutions be trusted to genuinely introspect and self-correct their internal structures that continue to foster systemic racism for the public good? I am not sure.6Olusanya BO Mallewa M Ogbo FA Beyond pledges: academic journals in high-income countries can do more to decolonize global health.BMJ Glob Health. 2021; 6e006200Crossref PubMed Scopus (6) Google Scholar, 8Olusanya BO. Dismantling structural discrimination in global health. JAMA Pediatr (in press).Google Scholar I agree with my colleagues from sub-Saharan Africa that the victims of racism must fight for their own freedom and dignity, participating in institutional processes radically and unwaveringly for real change.9Hirsch LA Is it possible to decolonise global health institutions?.Lancet. 2021; 397: 189-190Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar And if we must begin to tackle this moral and ethical menace head-on, independent monitoring mechanisms for holding the perpetuators and facilitators of racism accountable are imperative.10Olusanya BO Accountability framework to decolonise global health.Lancet. 2021; 397: 968Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar There cannot be a better time to enthrone humanity and justice in global health. I declare no potential competing interests.