2022•03•04

The Global Health Reflections series brings together opinion pieces, commentaries, and summaries of major issues related to global health. It is informed by the research and activities of UNU-IIGH fellows and our partners.

By Putri Widi Saraswati, MD, MSc (Research Intern, UNU-IIGH)

When asked about how I decided to go for a public health degree, I always start with the same story about a particular girl. Let’s call her ‘Luna’. Luna was a 16-year-old girl from one remote corner of northern Indonesia, my home country. I met her around 2014 when I worked as a community health doctor. Luna came from a low socioeconomic class and religious family, as most of the people in her village were. She was a high school student, something that she was afraid would not last much longer because she was pregnant. The man who impregnated her – whom she considered a boyfriend – was a 30-something-year-old married man with two children. At the time, teenage pregnancy was a common sight in that region and one of the common reasons many girls did not continue their education. Luna was very much aware of that.

I still remember how desperate and angry I was. I was angry at the man who had taken advantage of Luna. I was angry that I could not provide safe abortion – something that Luna asked for so she could stay in school – because I had never been trained and because abortion laws in Indonesia were, and still is, quite restrictive. I was angry because Luna said her family would only blame her. I was desperate because without access to education, Luna would have likely ended up without access to enough financial resources as well. Most of all, I was frustrated at my inability to do anything that could meaningfully help her. I had to let her go with empty advice, never to see her again. I never knew what became of her.

In 2016, my contract ended, and I went back home. Meeting Luna turned out to be a critical starting point for my feminist awakening. I started to get involved with local feminist activism networks, mainly around sexual- and gender-based violence (SGBV). I learned a lot from those activists. I was the only health professional within the network most of the time. It was also quite difficult to find fellow health professionals who shared similar feminist perspectives. I realised I was in a unique intersection between two sectors that, despite being intricately interlinked, never really talked to each other.

However, Luna’s case is just one example of how complex health can be for those who are not privileged enough. I spent a couple more years working as a general practitioner at private health facilities in my hometown. I remember sitting in my little practice room during those years, feeling more and more frustrated as I faced more clients with complex health problems for which I could not provide any meaningful solutions. I saw domestic violence victims who came with only the clothes on their backs and their children in their arms. I saw poor clients who were not covered by our national health insurance for some reason and had to sacrifice so much to access private healthcare. I saw more young people with unintended pregnancies. I saw LGBTQIA+ youth exposed to ill-health and violence and shunned from any support systems, including the health system and their own homes. I saw chronically ill clients who slowly fell into depression and lost access to meaningful lives due to their increasing disabilities. I saw working-class women who had to ‘choose’ between taking care of their health or their families at home.

It was a lot. It was frustrating. However, it was also motivating.

I came to the Netherlands in 2020 to pursue a master’s degree in public health. During my training, I was relieved to find the space in health that explores and attempts to address those complex issues. Finally, I was not alone. I found the concept of ‘social determinants of health’ a powerful tool to dive deeper into analysing two very important questions: 1) why certain people are less healthy than others beyond their so-called ‘personal choices’, and 2) what can be done about it. Relocating to Europe as a young woman of colour from a lower-middle-income country and studying among colleagues with similar backgrounds from all over the world highlighted another fact: the phenomenon is global. People around the world have less chance to be healthy because of who they are, where they live, or how much money they have. But critically, the way evidence is sought to understand and address these issues is also unequal. This realisation became even stronger as I was trained at the height of the COVID-19 pandemic – during which problems like global vaccine inequity became starkly evident.

So, what is the way forward? In my opinion, we can start by exploring the deeper questions – especially as health professionals. For example, instead of putting responsibility for healthy choices solely on individuals, we can start exploring the enabling environments – knowledge, access, availability, and affordability. We can start asking if structural and mitigating factors in people’s lives influence their ability to make the “right choices”. Furthermore, instead of putting it simply on individual knowledge, attitude, and behaviour, we can start asking about who has the biggest power to drive structural changes and create an enabling environment for people’s health.

As I write this article, the world is in the middle of a shock triggered by Russia’s large-scale armed invasion of Ukraine, which began on 24th February 2022 – in the 3rd year of the COVID-19 pandemic. There is clear evidence of the direct and indirect negative impacts of war and conflict on health, both short- and long-term. It has also been recognised that uniquely vulnerable populations, women and children, usually bear the brunt of it. Those currently happen in Ukraine as well. In addition, it has been reported that some refugees experienced racism. These are examples on how vulnerability can come in many different forms, including but also beyond gender. Gender and other factors that are parts of who a person is can intersect, amplify each other, and significantly influence their chance of (ill-)health. In global health, we have a responsibility to acknowledge that. Furthermore, we have to ensure that we monitor and provide the best evidence to advocate for those least able to advocate for themselves. We need to sharpen the lens to identify and mitigate systemic selective empathy and break down the power structures that perpetuate vulnerabilities and inequities.

We need to keep taking up spaces in global health – pushing if need be – by consistently asking difficult questions and doing our best to find the answers. That is the only way forward if we are to improve global health equity. And one day, maybe a final question will finally get the right answer: what if Luna were not the girl that she was?