Nasty Women, Leadership And Global Health

I was recently asked to speak about leadership in global health at the American Public Health Association annual conference in Denver. This got me thinking about the wave of interest in nasty women that started with the praise that Trump unwittingly granted to Hillary during his campaigns. It also brought back memories of my own dealings with nastiness that go back by at least a couple of decades.

For a long time, I had harbored an unconscious association between nastiness and leadership, especially when applied to women, but more broadly to all genders. I was surprised myself, and I only became aware of these feelings when I came to work at the MacArthur Foundation in the early nineties.

Not that I had not faced the idea of leadership before. Previously, some people in Brazil had promoted me as one of the leaders of the nascent feminist movement. However, I never took the idea of this leadership seriously. What movement, to begin with? At the beginning, we were just a dozen young women who were tired of being second class citizens, had read Simone de Beauvoir and Betty Friedan and thought that feminism would be a most revolutionary movement in the twentieth century. We had some visibility in the chattering class, and in the media, but that was because of how exotic we looked in the Brazilian ecosystem of the military dictatorship at the time. Oblivious to the joys and perils of leadership, I was focused on doing my research on gender inequalities, and trying to build a critical mass of researchers dedicated to the subject.

Before becoming the Director of the Population and Reproductive Health Program of the MacArthur Foundation, I was part of a group of outside advisors that were drafting the charter of the Foundation's program. These international advisors ended up recommending a 'Fund for Leadership Development', which would select promising individuals in mid-career and would provide them financial support for creating innovations in their area of expertise. This was the first time that I carefully examined the concept of leadership.

While I was a great supporter of this fund, and led its development and implementation in countries of Africa, Asia and Latin America, I was uncomfortable with the word "leadership" in its title. I was coming from the Latin American left, where the consensus was that social change is created by social movements, so-called leaders being no more than agents empowered by collective action. The ideal was the creation of non-hierarchical organizations, and rejection of individualistic mindsets that we saw as the source of all that was wrong.

However, this attitude towards leadership was not exclusive in Latin America. Gandhi blurred the line between leaders and followers when he said: "There go my people - and I must follow them, because I am their leader"!

In addition to the political dimension, there were social norms that dictated that leaders, if they were needed at all, should emerge as a choice of the group, never as a planned process in which the ambition of the individual could be a starting point. To step up with the intention of being a leader would be considered bad manners and presumptuous. For women, it was clear that only nasty women, very nasty women would want to do that.

After numerous discussions with my colleagues who thought differently, I accepted "leadership" in the name of the program, and tried to help change the very meaning of the word. The program looked for collaborative leadership that was close to the grassroots and respected and promoted the voice of the voiceless. We supported people, and women in particular, who were nasty enough to reject the "bad, old ways" and fight for social justice and women's rights. In the following years, many of the beneficiaries of the program had distinguished careers exercising different forms of democratic leadership and accomplishing important outcomes for the public good. A few of them, however, faced deep resistance in their communities, especially among indigenous populations. This experience has thus shown me the need for different approaches to leadership according to the context.

When it comes to global health today, I believe good leadership is essential. (I mean nasty, good leadership). In spite of significant progress in global health, the challenges are still huge, and the political, social and economic environments are terribly complex.

It may be that it is not in spite of progress that challenges are huge but because of progress that challenges are huge. Because of past progress, we know that further progress is possible. Because of past progress, expectations are higher, and future rate of progress needs to be much faster. The Sustainable Development Goals approved by the countries of the world at the UN last year are ambitious and the goal of reduction of maternal mortality, for instance, needs to be three times faster as the rate of change achieved during the MDGs.

Additionally, we should not forget the great progress we have made in knowledge. We are now much more aware of problems that were below the radar before. Think, for instance, about the epidemic of sexual violence throughout the world. We still have poor data, but what we have is enough to show the urgent need to act.

We have also made progress in learning how complex the solutions are. Take, for instance, maternal mortality. We now know how closely it is linked to the lack of sexual and reproductive health and rights. The "safe motherhood" approach of earlier decades looks quaint today, when it is clear that it is anything but safe, to ignore the toll of lack of services for abortion and for contraceptives. These services are simple to provide, but the politics involving them are anything but simple. It requires deft leadership and nasty leadership to shake the comfortable avoidance of difficult issues of the past.

We have also learned from our failures. We are now aware of the depth of inequalities, the mechanisms of their perpetuation, and the appalling consequences not only for the billions of women, children, adolescents and men at the lower end of the spectrum, but for the social fabric itself, for the improvement of our political systems, and most menacing of all, for the survival of the planet. Changing course requires visionary leadership with practical (even nasty) skills of making things happen.

We have also gained valuable insights from the vast literature on social and political determinants of health. Much of the improvement in health depends on non-health sectors. Global health plans are now clearly linked to cross-sectoral work. This is the case of the SDGs and is the case of the 2016-2030 Global Strategy for Women's, Children's and Adolescent's Health. The important positive and negative roles of the complex private sector are now receiving greater attention. The role of civil society, both as advocates and as providers, was never so prominent and so threatened. Within the public sector, education, WASH and other sectors, can no longer work in separate silos. Forceful and diplomatic leadership is needed to make collaboration across sectors a reality.

Progress has also come in the demand for accountability. The global health community is no longer satisfied with good plans and nice promises. There is now a thirst for effective mechanisms for ensuring accountability for implementation of the internationally agreed goals. A new synergy between health and human rights is bringing new approaches to fostering health outcomes and protecting the rights of everybody, without discrimination or neglect.

Accountability requires transparency and solid data for measuring results, and it also requires participatory mechanisms to ensure remedy for violation of rights, and allocation of resources to prevent and correct inequities. To make this transformative change requires bold and effective leadership at all levels.

For all these reasons, leadership is one of the three overarching recommendations of the recently released report of the Independent Accountability Panel for the Global Strategy for Women's, Children's and Adolescents' Health, the distinguished panel of which I have the privilege of being the co-chair. In the report we presented to Ban KI Moon during the General Assembly we recommended that the new Secretary General of the UN and the new Director General of WHO be committed to the health of women, children and adolescents, committed to accountability and committed to cross-sectoral work. We also believe similar leadership is needed at every level - at local, national, regional and global levels.

In sum, global health is at a cross-road facing huge and complex challenges. But the good news is that global health can build on the progress already achieved in many realms. Progress in knowledge and implementation has developed new solutions as much as it has uncovered long neglected problems. Gross inequities have become intolerable, and the demand for accountability is mounting.

Today more than ever we need leaders who are visionary, have integrity and strive for equity. These leaders need to be diplomatic and efficient to make things happen, but nasty enough to fight the battles that need to be fought in order to transform this world and to make it a world worth living in.