“To exclude is human, to include, divine.”

Bisi Alimi

Global health is witnessing a crescendo of demands for a more equitable future and persisting challenges facing health systems across the world. While exclusionary policymaking and the inequitable distribution of medical solutions and services became glaringly apparent during the COVID-19 pandemic, the intent and capacity to make global health inclusive are more protracted issues. Epidemics expose and exacerbate existing inequalities. Part of the problem is that the decision-making process in global health is opaque and prioritizes the voices of stakeholders with social and financial capital. Against the prevailing disparities, one must remember that the vision for equity was enshrined nearly five decades ago in the 1978 Alma Ata Declaration on Primary Health Care. Thus, inequity in global health is both an inherited and unfinished problem.

Equity is not just about fairer country representation. Structural discrimination manifests in complex ways within countries and even across seemingly homogeneous contexts. In some African countries, the COVID-19 response excluded sex workers from safety nets, forcing them back into the outdoor work environment during lockdowns. The imposition of stringent lockdown measures was not accompanied by a continued availability of essential health services, e.g., access to antiretrovirals for people living with HIV. Given the irregular access to drinking water, the prescribed measure of frequent handwashing was not equally afforded by all. When 75% of the entire population of Western Europe had been vaccinated, only one-quarter of African health workers had received the COVID-19 vaccine. A lesser-known fact is that, even at the end of 2023, 2.2 billion people still had yet to receive a single dose of the vaccine — with 89% of these people living in developing countries.

At the O’Neill-Lancet Commission on Racism, Structural Discrimination, and Global Health (the Commission), we operate with the ambitious and urgent mandate to identify and confront entrenched inequities plaguing global public health. With this mandate, the Commission has organized multiple consultations and convenings with stakeholders in global health to discuss the practices and outcomes of exclusionary decision-making on people and communities pushed to the margins.

In November 2023, the Commission held a consultation, “Promoting Inclusion in Decision Making for Global Health Governance: Lessons from Africa’s New Public Health Order,” at the third International Conference on Public Health in Africa (CPHIA) in Lusaka, Zambia. At this event, we convened public health experts directly involved with Africa’s COVID-19 response and decision-making.

Bisi Alimi, a renowned LGBTQI+ advocate previously engaged in the HIV/AIDS response, delivered the event’s keynote address. Sharing his experiences in HIV/AIDS advocacy and subsequent disillusionment with the public health sector, Alimi emphasized the largely unchanged issue of myriad, systematic exclusions. During the early 2000s, the AIDS response in Nigeria largely invisibilized the circumstances and needs of young gay men, leaving them more vulnerable to infection. Further, legislative antipathy towards homosexuality across many countries has worsened the institutional safeguards of those marginalized based on sexual orientation. Alimi foreshowed the blatant linkages of public health with religion, patriarchy, ableism, racism, and white supremacy. The entanglement of science and medicine with law, politics, policies, religion, and social norms makes interdisciplinary dialogue and multisectoral collaboration an indispensable need.

At the event, Dr. Matshidiso Moeti, WHO regional director for the African region and the first woman elected to that position, argued that “[to] support, speak on behalf of and protect people, you must know them, be in touch with them, and be able to understand their experiences.” This fundamental shift requires influential actors to understand and accept that prevailing problems will not be solved without the proactive and respectful involvement of those living on the peripheries of power and most vulnerable to the threats we face today. In addition to involving marginalized communities in creating and designing programmatic interventions, public health must scrutinize how the response to social determinants of health remains entrenched in religious morality and criminal legislation.

Bisi Alimi called this “intentional inclusion” — a shift requiring those at the top of the health governance hierarchy to travel the distance from condescension to humility. For instance, Africa’s pandemic response offers many lessons learned. The Africa CDC, in partnership with multilateral, regional, and multisectoral entities, created platforms for designing and delivering preventive and therapeutic solutions.

However, is the global health regime prepared for the cognitive shift in seeing the continent as a leader and not just a recipient of public health intervention? As the member states of the World Health Organization move to negotiate a new modality for pandemic preparedness, we call for the adoption of explicit and intentional inclusivity. This approach thoroughly scrutinizes those missing or underrepresented in spaces where policies are made, decisions about technology transfers and resource allocation are taken, and global health problems are defined and prioritized. These spaces remain arenas of racial, class, and regional privilege. Ultimately, intentional inclusion would reconfigure the benchmarks of success and failure based on who gets a seat at such decision-making tables and who gets left behind during the next public health crisis or emergency.

DISCLAIMER: The views and opinions expressed in this piece are those of the author and do not reflect the views of the O’Neill Institute.