Power and prejudice: How does inequity play out in the institutions and processes of health systems

Co-facilitators Kate Hawkins (RinGS), Roopa Dhatt (Women in Global Health), Sreytouch Vong (RinGS), Rosemary Morgan (RinGS & John Hopkins), Kati Wilkins (Women in Global Health), and Sarah Ssali (RinGS).

The room was buzzing at the Global Symposium on Health Systems research with a new kind of energy as conference attendees found themselves in a rare engagement about power and prejudices, in relation to their own professional, political and personal lives. The participatory dialogue opened with a short presentation – with a clear goal - “To help us begin thinking about inequities within research systems, organisations and institutions. To shine a light on persistent weakness in our systems of knowledge generation and exchange.”

Kate Hawkins opened the session by deconstructing her own privileges and vulnerabilities, for example that she is a white, English, cis, heterosexual, middle-class, middle-aged woman, who probably had the fewest years of formal education of anyone in the room. Her presentation used a combination of sources – news clippings, twitter, and research articles to bring attention to multiple layers of power – related to race, gender, sexuality, expertise etc. – that exist in our organization and institutions. It provided insights from the UK which aimed to prompt thinking from other settings. The presentation challenged the way that those raising questions about class, race, gender etc. in academia often get dismissed as playing ‘identity politics’. It questioned positions of ‘neutrality’ by suggesting that we all occupy political positions even if our positions appear to be the ‘norm’. In relation to health systems research two inter-related concerns rose to the top – researchers have mindset biases that result in them failing to sufficiently consider gender and other forms of intersecting inequity as social norms, and that analysis of the field of health systems research and its governance has failed to adequately take this into account.

Power and Prejudice within Academic Institutions: from the literature

The presentation highlighted the institutionalized sexism within UK academia and how this intersects with other forms of discrimination with regards to race, class etc. For example, a study by the National Union of Students in the UK found that sexual assault is significantly underreported, and “only 4% of women students experiencing serious sexual assault report to their universities” (source @alisonphipps). Only 15% of scientists in the United Kingdom come from a working-class background (source @hcpearson). UK academia is also racist, in a study by Bhopal of 65 black and minority ethnic academics from the UK and the US a majority “said that they had experienced some form of racism or racist bullying – including all the UK-based interviewees.” Indeed there are only 18 Black women professors in Britain (source @AkwugoEmejulu).

It went on to look at the costs and the benefits of three significant institutions that support progression within academic are academic conferences, peer review, and collaboration.

1. Conferences

A lack of gender parity in conference spaces is hard to ignore and is one of the reasons for the protest hashtags that make visible and decry all male panels. But conferences also create exclusions due to unaffordable fees, a lack of childcare, advance payment, abusive border control practices, lack of disabled access, exclusionary communication styles etc.

2. Peer Review

In terms of citation one piece of research that looked at 1.5 million studies published between 1779 and 2011 found that men cited their own papers 56% more than women on average. Analysing a database containing 25 years of articles from the 12 leading International Relations journals, a study by Maliniak et al. found that over a period of several years, the average number of citations of articles authored by men alone was about 25 while it was about 20 for articles authored by women alone. This may seem like a small difference, but the average article in the humanities and social sciences hardly gets cited at all — on average, less than once a year — so even these small numbers strongly impact the perceived quality of the work. Men cite men more (including citing themselves) and women cite women more. So, if a field is 80% men and 20% women, then of course the work of men is going to get a lot more citations than the work of women.

3. Collaboration

Collaboration is often considered straightforwardly beneficial for all involved. However, we are increasingly seeing analysis that considers North-South collaboration in the context of movements to decolonize education, questioning its benefits to low-income countries. A recent study of collaboration on journal articles found that in economics women suffer a “coauthor penalty”. While women who solo-author everything have roughly the same chance of receiving tenure as a man, women who coauthor most of their work have a significantly lower probability of receiving tenure. In addition, when women collaborate authorship with men, they get zero credit, because it is assumed that “the man” must have been the expert .

This presentation set the tone for a session about politics that was self-reflective and unveiled a conversation about the inequities that exist in our institutions and processes of health systems research.

Power and Prejudice within Academic Institutions: Participant concerns

Power, prejudices, privileges influence decision making, resources, role and responsibilities at all levels in research. Participants reflected on their own political, professional and personal lives to shift the prejudicial structures and institutional systems that work counter to research excellence, including identifying the weakness in our systems of knowledge generation and exchange. Some of the issues that arose included:

1. ‘Foreign’ Status:

We heard that international trainees only get partial experience on health systems courses as there are numerous reminders of how they are outsiders - from the structure of the course work to the low expectations set by being disqualified from post-doctoral positions, as many institutions do not offer positions to foreigners. Additionally, many echoed concerns that academic conferences are often held in countries that are inaccessible either due to regulatory challenges (i.e. borders, visas) or financial barriers (remote locations or costly destinations) become a barrier for researchers. Participants also felt that norm setting for academia is dominated by countries in the global north and this results in a system that places certain people at advantages and other at disadvantages.

2. Academic Processes:

Standardized exams (GRE) become barriers to access higher study and promote people with certain privileges – i.e. those with greater financial resources, English as a primary language etc. We heard that in many settings gender discrimination means that women are less likely to be promoted to professorship positions, as it is perceived they will be care takers eventually. Rigidity of academic organizations was considered a problematic issue. Academic and research institutions are founded upon tradition and are resistant to change by design and therefore, certain groups continue to have more power and privileges. In addition, research agendas are set by economic and other interests, not necessarily for social good or interests of the researcher.

3. Junior Status vs. Senior Status and Ageism:

Participants talked about the challenges of being a ‘junior’ member of a research team and being tasked with the greatest work load and then not receiving credit in publications or (first) authorship. We talked about the researcher ‘lifecycle’ whereby one is not valued at early or late stages, therefore, there is a short window of when one is valued within academia leading to discrimination and exclusion.

4. Validated Research:

Given that qualitative research is less validated in certain settings it undermines certain researchers and becomes a form of discrimination on what is considered factual or evidence. [Office3]

5. Understanding our own positions of power and privilege

It is common that those who inhabit spaces of power are the ones least likely to grapple with issues of power and privilege - the makeup of the room itself was testament to this. It is important to understand our own positions of power and privilege and how we might use these to dismantle inequity within academia. Questions that were raised include: What types of power does our gender, race, or age give us? How can we begin to shift power imbalances within our own institutions and use our own power to give space to those without it? Those who inhabit positions of power and privilege must not be afraid to unpack these, speak up about it, and use it to challenge the current power structures within our institutions.

Five “S”s emerged as a way forward:

Self - the individual power and the challenge to ourselves to challenge and deconstruct norms and biases that are discriminatory. We can bring greater visibility and credit to more people.
Space and context - this is the power that emerges from one’s geographical, physical, or other spheres of influence and the ability to both leverage and transform these. This has particular power when it comes to making spaces more inclusive.
Shifting power – it is important to remember the dynamic nature of power in order to work to counter its harmful discriminatory impact.
Systems - power works within systems. Recognizing this is important in designing solutions, whether the barriers are gender, age, financial, policy etc.
Solutions for social change - willingness to change itself is power. In research settings, data and measurement itself becomes a source of power that we can use to make significant change.