Global health is a field that was born out of colonialism and white supremacy. Even today, it is neither diverse nor truly global. Every aspect of global health is dominated by individuals and institutions in high-income countries (HIC). This includes funding, authorship of publications, leadership of agencies, composition of boards, editorial positions, awards, and even participation in conferences. So, if global health has to be reimagined, people that typically hold power and privilege must master the art of allyship, where they see their primary role as allies or accomplices rather than leaders.
Data show that two-thirds of global health agencies are headquartered in just three countries: Switzerland, UK and USA. More than 80% of CEOs and board chairs of global health organizations are nationals of HICs. Leadership across the global health sector is mainly in the hands of older men from 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.
In short, global health is firmly centered on those with power and privilege, and focused on their generosity and saviorism. We see this right now, with Covid-19 vaccine inequity. Rich nations have hoarded vaccines and their trickle-down charity model has ensured a prolonged pandemic.
Given these deeply entrenched power asymmetries, there is a growing call to decolonize the global health and development sectors. This requires a serious analysis of intersectionality and power.
“A critical analysis of colonialism is fundamentally intersectional and must locate its construction, and thus, deconstruction, in the intersection of white supremacy, global anti-Blackness, patriarchy, capitalism, ableism, classism, homo-transphobia, fatphobia, and xenophobia,” said Ijeoma Nnodim Opara, a physician and assistant professor at Wayne State University School of Medicine.
Allyship is one way to address these systems of oppression. “I think the most crucial aspect of allyship is the awareness of the power difference between the two parties. I think once this is explicitly discussed, allies can come up with mechanisms that alleviate this difference (to some degree),” said Rafia Zakaria, author of Against White Feminism. In her book, Zakaria writes that meaningful allyship requires people used to privilege to experience de-privileging of their perspectives. Real allies need to cede space or voice or power, she argues.
What can allyship look like in global health? People in HICs can be allies to people in LMICs. White people in global health can be allies to Black, Indigenous and people of color (BIPOC) people. Men in global health can be allies to women. Able-bodied and cis-hetero people can be allies to people with disabilities and LGBTQ+. The list goes on. But what is allyship and how can one practice allyship?
What is allyship?
The Anti-Oppression Network defines allyship as “an active, consistent, and arduous practice of unlearning and re-evaluating, in which a person in a position of privilege and power seeks to operate in solidarity with a marginalized group.”
The Anti-Oppression Network expands the above definition by stating:
allyship is not an identity—it is a lifelong process of building relationships based on trust, consistency, and accountability with marginalized individuals and/or groups of people
allyship is not self-defined—our work and our efforts must be recognized by the people we seek to ally ourselves with
“Allyship is not an identity. It is a practice,” said Stephanie Nixon, a professor at the University of Toronto. “I find the framing of ‘ally’ as a noun to be an unhelpful distraction at best, and a powerful technique for further entrenching the status quo at worst,” she clarified. Nixon has proposed the Coin Model of Privilege and Critical Allyship, where she calls on everyone working in health to (1) recognize their positions of privilege, and (2) use this understanding to reorient their approach from saving unfortunate people to working in solidarity and collective action on systems of inequality. Her video offers tips for effective allyship.
“I have been using the term co-disruptors more and more. And have been urging people with more social capital due to privilege to at minimum be an upstander (rather than an ally),” said Amy Tan, a Clinical Associate Professor, at the UBC Faculty of Medicine. “An upstander means that a person will use their privilege, actively stand up in the fight against oppression by speaking up against the oppression (while being careful to not speak for the person or groups experiencing oppression),” she added.
“To achieve global health equity, those who are the most burdened must be centered and should lead efforts to develop and implement policy and programmatic solutions,” said Oni Blackstock, founder and Executive Director, Health Justice. “Co-conspirators — people with (unearned) privilege and influencewho want to partner in this work — must step back and ask disproportionately impacted communities how they can support these communities in gaining access to the resources and life-affirming opportunities needed to achieve optimal health and wellbeing,” she explained.
“An ally uses their power to disrupt and undermine the systems in which they wield power, accepting that building a more just world requires them to yield power,” said Layth Hanbali, freelance researcher focusing on health policy. “Allies must be willing to give up their own seat at the table and work for others with power to do so, rather than adding another seat,” he emphasized.
How can white people practice allyship?
White people in global health hold enormous power and privilege and are often leaders of global health agencies and projects. This is true since colonial times.
“White people need to pause, listen and engage in discomfort,” said Heather Buesseler, an independent consultant in compassion and equity-centered health systems design. She has penned a letter addressed at white people, on decolonizing global health. “If decolonization is to succeed, White folx cannot be the ones leading it. We need to step back and re-center power and decision-making so Black and Brown people from the Global South are the ones defining the agenda and designing the seating arrangements at the game table,” she wrote in her letter.
“In global health, White folx jump in, we make things move, and we start solving problems even before we’ve adequately understood those problems and before we’ve built relationships with the people with whom we are working and serving,” she explained. “Instead, we need to consciously practice humility to listen, ask, understand, incorporate, and amplify the perspective and ideas of those we serve, who are mostly Black and Brown people in the global South,” she elaborated.
“To me, allyship in global health looks like white women and white men in positions of leadership leaning out and giving space for more representative leadership,” said Lazenya Weekes-Richemond, a global health professional. “As a black woman in global health, there’s an unspoken hierarchy and I’m often on the bottom of the rung with little agency despite having more field and technical experience than many of my white female counterparts. I want to see white women really listening to BIPOC women, valuing the unique perspective they bring, speaking up on their behalf, amplifying their voice and challenging their organizations to actively dismantle the systems of oppression – that for me is true allyship,” she explained. Her article “Dear White Women in International Development” offers more insights.
“We will never achieve global health without including the voices of BIPOC communities at decision-making tables. White people must transition from their roles as allies to become co-conspirators who use their privilege to uproot pillars of oppression. It is no longer sufficient to create room for BIPOC people in spaces where they have been historically excluded. However, it is imperative for white people to give up some of their seats for better representation of BIPOC communities and to foster equitable health for all people worldwide,” said Birgit Umaigba, Clinical Practice Instructor, Centennial College, Toronto.
“There is a real need to connect lived experiences and local priorities to global agenda-setting and national policy. We must recognize that the global decision making apparatus was not designed for the majority of the world who I refer to as formerly colonized and enslaved people, and was designed without them at the table. The global system is inherently exclusionary which upholds systems of structural violence. The apparatus in place does not meaningfully allow leadership of those with lived experience. It needs to be taken apart and radically reimaginedto center women, brown and Black people, and oppressed people in both the so-called ‘Global North’ and ‘Global South’,” said Sarah Hillware, a global health equity leader & advocate.
How can Global North (HIC) people and institutions practice allyship?
Since people and institutions in HICs call the shots in all areas of global health, they have work to do.
“People in HICs must actively disrupt dominant power relations by both relinquishing their own privileges and fighting against them at their institutions and with funders, but, more importantly, forfeiting attractive grants that work towards the credentialing of those who should be paying higher taxes to adequately finance a real change in global health equity,” said Irene Torres who works at the Fundacion Octaedro in Ecuador. “At the very least, they must create the mechanisms for, promote and support divergent thinking and practice, based on a genuine participation (as opposed to token, that is, requiring ethical symmetry among all) to scaffold marginalized -or made invisible- people from civil society and communities towards collectively gaining greater control and power over their lives,” she added.
“True allyship is for the more powerful to completely stand back and let those who have been forever marginalized from the sector, to take control of their contextual and operational environment,” said Themrise Khan, a global development expert in Pakistan. “Allyship isn’t about being a friend. Its being aware of your power over others and being willing to give it up,” she argued.
“The only way true global health allyship can be meaningful is if all allies are equally invested and contribute towards projects,” said C S Pramesh, a global oncology expert at Tata Memorial Hospital in India. “Often, we find north-south relationships skewed towards ideas and thoughts of the global north being imposed on the collaborator(s) from the global south, and these are doomed for failure. For success, involvement and leadership from local collaborators is imperative,” he explained.
How can men practice allyship?
Privileged men from elite institutions in the global north wield great power in global health. Thus, men must find ways to lean out, and create space for women and diverse expertise.
“It is critically important that men have skin in the game as we fight together for gender equality,” said Shereen Bhan, Acting North America Program and Global Leadership Development Director, WomenLift Health. “We will not achieve true diversity in leadership until we recognize that the success of men and women is bound together. Men can help remove the top hurdles to advancement in women’s leadership by pushing policy for improved work/life harmony, by sponsoring women, by helping female colleagues navigate institutional politics, and by working towards a more supportive and inclusive environment. Men gain from the unique skills and lived experiences that women bring to the table,” she explained.
“Male leaders in global health, who want to be better allies to women in dismantling structures of power and privilege, can practice six key things: 1) have sincere intent and recognize their own privilege; 2) listen with patience and remember that it’s not about them; 3) talk less and act more; 4) advocate and sponsor instead of just giving advice; 5) create and recommend opportunities for leadership growth; and 6) amplify and bring visibility to diverse voices across the intersections of gender, race, class, and citizenship,” said Mehr Manzoor, Fulbright Scholar & PhD Candidate, Health Policy and Management, Tulane University.
“A great example of male allyship that comes to mind is from an experience in a previous role I held at a large organization, where I found out I made significantly less than a male colleague with a similar level of experience,” said Sarah Hillware. “I had an informal conversation with a white male colleague and he shared how much he made and informed me how much I was eligible to request. I used this information to move to another department and obtain a 20% pay raise,” she explained.
How can able people practice allyship?
“Able people must recognize systemic ableism and how it intersects with other forms of marginalization, and how these intersections influence and transform human health, disability, and well-being,” said Aparna Nair, Assistant Professor, History of Science, University of Oklahoma-Norman. “We must understand that many disabled people across the world have experienced public health and biomedicine in violent and oppressive ways; and that that history continues to resonate today. So, we must engage meaningfully with (involve them as stakeholders) disabled people’s voices, opinions, activism, and advocacy,” she emphasized. Her forthcoming book “Fungible Bodies” examines the relationship between disability and colonialism in British India.
“We have an inequality crisis around disability,” said Shubha Nagesh, Chapter Development Manager, Asia-Pacific & Middle-East, Women in Global Health. “Recognizing the unique challenges faced by persons with disabilities, there is a need for institutions to build more comprehensive diversity policies and practices that create an inclusive environment for leadership and decision-making. Allyship can shift the narrative for persons with disabilities. It’s our differences and our unique experiences that will steer us towards our collective vision of a more fair world,” she argued.
How can cis-hetero people practice allyship?
“Allyship that benefits queer people must, foremost, involve a sincere recognition of hetero-cis-normativity as the world’s dominant mode of operation, across all social spaces, including global health,” said Suntosh Pillay, a clinical psychologist at King Dinuzulu Hospital in Durban, South Africa, and researcher in the African LGBTI+ Human Rights Project. “Allyship must therefore confront and undo these exclusionary assumptions by ensuring that queer people from diverse contexts are always given a space for their voices to be heard. The best forms of allyship involve humility, respect, collaboration, and both emotional and material support for particular causes,” he added. He recently co-authored an article on how global health under-represents the experiences of LGBTQ+ people.
“It is important for cis-het allies from global health to recognize that the struggle of LGBTQIA+ folks is political, said Aqsa Shaikh, an associate professor at the Hamdard Institute of Medical Sciences and Research, Delhi. “We need allies to amplify our voices against systematic political, legal and social exclusion. We need allies to support our right to live – identifying as an LGBT person in many countries is punishable with death. Allies need to identify, amplify and support voices of queer persons especially those with multiple marginalizations. Instead of relying on just cis, gay, white men from the Global North, how about listening to queer folks with layers of marginalization, like a Dalit trans woman from India?,” she asked.
How can non-Indigenous people practice allyship?
“Indigenous allyship is the ongoing and active process of building, nurturing and maintaining relationships with Indigenous peoples and then supporting them to achieve self-determined priorities,” said Lisa Richardson, Associate Dean for Inclusion & Diversity at the University of Toronto Faculty of Medicine. “The concept of self-determination is that Indigenous communities determine goals and priorities—an ally’s role is to help in the realization of them. Allies must be accountable to processes that are respectful of Indigenous leadership and ways of knowing, and that uphold Indigenous rights,” she added.
“In my perception, allyship is starting to be viewed as a belief system, rather than a way of being,” said Pamela Roach, an assistant professor and director of Indigenous health education at the University of Calgary. “We need actionable words that speak more to behaviors, like accomplice, to shift non-Indigenous allies into action rather than just beliefs. It’s the action and behaviors that evidence true allyship and can work to create true change within systems that is important,” she explained.
“We need more advocates and allies, we need to have the microphones, the seats in panel discussions, in board rooms and to stop being the afterthought or the token inclusion, that is what allyship should look like,” said Faye McMillan, an associate professor at UNSW, Sydney, Australia.
Beyond allyship: striving for trust, solidarity and collective liberation
Many of the experts I spoke to felt that allyship may not be sufficient to reform global health. Learning about effective allyship is just the start. But, as Morpheus warned Neo in The Matrix, knowing the path is not the same as walking the path.
Tiffany Jana believes that contemporary allyship remains entirely too personal and self-centered. “You can be an ally and do nearly nothing,” she wrote. She encourages us to move along the continuum from allies to accomplices, and to become co-conspirators.
Layth Hanbali concurs. “Instead of ‘ally’, I am increasingly drawn to terms like ‘accomplices’ and ‘co-conspirators’ as they imply an active, disruptive process,” he said. He points out that many institutions have recently deployed progressive rhetoric (e.g. statements or events about Black Lives Matter or decolonizing global health) without accompanying action. “Most have done next to nothing to challenge structural racism, give land back, or make reparations for the systems that created these injustices, which are the same systems that create and maintain the influence and wealth of these organizations. Demanding ‘accomplices’ and ‘co-conspirators’ may raise the bar to require action beyond discourse,” he argued.
“I don’t aspire for allyship in my personal interactions, professional activities, and activism,” said Monica Mukerjee, aid worker, who has been active in groups like Decolonise MSF and NANSHE. “Instead, I find myself constantly reflecting on demonstrating trust and commitment. Am I embodying values and behaving in ways in my daily life that are trustworthy for people affected by different and more oppressions? Am I taking risks to dismantle inequitable systems proportionate to my own privileges? Am I joining my voice alongside those who have been spurring change before me? Am I ceding space to allow those more historically marginalized than me to have voice and ownership? Am I listening, taking responsibility, and growing when others hold me accountable for my own mistakes, biases, and limitations?” she asked.
“If we focus on getting to solidarity, within and across all groups and intersectional identities, I think that this is where real change can happen,” said Amy Tan. “Oppression affects us all, but in different ways and anti-oppression really must be the universal goal,” she explained.
Stephanie Nixon agrees. “We need to reorient allyship according to collective liberation – none of us is free until all of us is free,” she said. “This means showing up with humility and openness, willing to use the power and safety that comes with the body they’re in to act in solidarity and with accountability in collective action toward a more just future where all are free and safe,” she explained. Her article includes a quote from Indigenous elder, Lilla Watson, that seems especially relevant to everyone in global health: “If you have come here to help me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together.”