A global health response to gender justice requires continued engagement

The 2021 Global Peace Index reports a significant deterioration in global peace over the last fifteen years. [1] The Global Humanitarian Overview 2021 reports an increase in the number of people in need of humanitarian assistance from one in 45 to one in 33 over the last year. [2] Both reports document the additional impacts of the covid-19 pandemic and climate change. Both reports predate recent events in Afghanistan, Tigray, Northern Nigeria, Yemen, Syria. 

The immediate and obvious harms to health and wellbeing are evident, as are the devastating reversals in hard-won progress on gender equality, health equity, and human rights. Current events in Afghanistan provide a stark illustration, and while no longer front page news, other current examples from Myanmar, Tigray, and Nigeria—to mention a few—point to how the erosion of rights and health for the world’s most vulnerable is increasingly becoming not only of concern, but the status quo. [3-8] These challenges are not confined to countries in a state of crisis, conflict, or instability. Globally we are witnessing regressive politics and democratic deficits that endanger the realisation of fundamental principles of equality and universal rights across a range of settings. It is increasingly evident that democracy, freedom, and the protection of human rights are not guaranteed even with “free and fair” elections. Those who suffer most will always be those who are most marginalised. 

Beyond the immediacy of the humanitarian response, we, collectively, as a global community of global health experts, have an obligation not only to continue to promote, but to strengthen the underlying values of social justice, equity, and human rights—not just in rhetoric, but also in our practice. This must be done, recognising the risk of harm to communities with whom we engage in these settings, particularly where political or religious ideologies drive inequity. [9,10] For example, the immediate response to the situation in Afghanistan has been to pull out all aid and humanitarian staff and actively encourage all qualified people with links to agencies to leave. The consequence is often mass emigration of those who can leave from local communities and international aid agencies. This may represent brain drain that leaves many sectors and essential services bereft of much needed technical expertise. 

The humanitarian sector has a range of guidance available for delivering health interventions during crises and conflict. [11] Humanitarian work is governed by core principles that may provide a useful approach and valuable lessons for global health practice. The principles include the overarching principle of humanity and neutrality, impartiality, independence, and collaboration/partnership. [12] Humanity highlights the need to address human suffering, protect life and health, and ensure respect and dignity. Neutrality prevents humanitarian actors from taking sides in hostilities relating to political, racial, religious, or ideological controversies. Impartiality ensures a focus on prioritising actions based on the urgency of need. Independence guides action that is autonomous from political, economic, or military influence. Local collaborations and partnerships are critical to ensuring the appropriateness and sustainability of solutions in the local context.

Despite some contestation in the interpretation of neutrality and impartiality, the protection and promotion of gender equality, or the rights of discriminated individuals, do not violate these principles. [13] Secondly, when the humanitarian response begins to evolve into longer term development and reconstruction, the principles of neutrality and impartiality can still be employed in negotiating new ways of working through questioning discrimination and inequality. The humanitarian principles are intertwined and inseparable, allowing for action to challenge and change inequities as core to the overarching principle of protecting humanity. Neutrality and impartiality in this context should be interpreted to mean that irrespective of the philosophy of any governing regime—rights to health and wellbeing, equality, and non-discrimination are universal. Humanitarian and aid personnel on the ground for the long term are progressively amassing experience and expertise, grounded in the realities of the local context. Their presence has proved critical to local populations, support, and building trust and credibility over the longer term, providing critical lessons on the core components for dialogue and progress. Approaches like these are important for achieving health goals because justice and gender equality can promote virtuous cycles of peace and stability. [14]

The global health community justifiably expresses shock and concern over unfolding crises from Afghanistan to Ukraine. Beyond condemnation, we recommend that the global health community consider the following:

  1. Achieving global health goals necessitates addressing the underlying inequalities and injustices of peoples’ lives. This is not a short term activity. This requires trust, relationship-building, nuance, pragmatism, and understanding the politics of a situation. It also requires engagement with the systems and processes that shape the environment where people live. 
  2. Context is king (queen!). The gut response to injustice is an important galvaniser for action, but we need to learn how to engage better with the social, cultural, economic, and political context through genuine collaboration with those who live and work in the various contexts.
  3. Health equity and gender equality are powerful and underutilised tools towards peace and prosperity. [14] Concerted efforts to enhance our practice will yield multiple benefits.

The world is at a critical juncture; the threat of authoritarian regimes undermining human rights and equality are very real. The global health response in humanitarian or development settings can no longer claim to be doing its job by just providing health services and focusing on health outcomes alone. More than ever before, our global health practice needs to adhere fully to the principle of humanity by promoting health equity, gender equality, and human rights as a part of our core responsibility, recognising the nuanced understanding of the economic, social, cultural, and political contexts in which we work.  

Pascale Allotey, Director; United Nations University International Institute for Global Health.

Elhadj As Sy, Board Chair, Kofi Annan Foundation.

Zulfiqar A BhuttaCo-Director, Centre for Global Child Health; Founding Director, Institute for Global Health and Development. Centre for Global Child Health, The Hospital for Sick Children, Canada; Institute for Global Health and Development, The Aga Khan University, South Central Asia, East Africa & United Kingdom.

Peter Friberg, professor and director, Sahlgrenska Academy at Gothenburg university, Gothenburg, Sweden, and Swedish Institute for Global Health Transformation, SIGHT, at the Royal Swedish Academy of Sciences, Stockholm, Sweden.

Sofia Gruskin, professor and director, Institute on Inequalities in Global Health, University of Southern California.

Geeta Rao Gupta, senior fellow, United Nations Foundation.

Sarah Hawkes, professor and director, Centre for Gender and Global Health, Institute for Global Health, UCL.

Competing interests: none declared.


1 Institute for Economics and Peace. Global Peace Index 2021: Measuring Peace in a Complex World. 2021; published online June. https://reliefweb.int/sites/reliefweb.int/files/resources/GPI-2021-web.pdf (accessed Aug 30, 2021).

2 United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Global Humanitarian Overview 2021. https://reliefweb.int/sites/reliefweb.int/files/resources/GHO2021_EN.pdf (accessed Aug 30, 2021).

3 Bhutta ZA, Akseer N, Dalil S, Akbari A, Saeedzai A. Afghanistan is at a crossroads again—preventing a descent into chaos. The BMJ 2021; published online Aug 19. https://blogs.bmj.com/bmj/2021/08/19/afghanistan-is-at-a-crossroads-again-preventing-a-descent-into-chaos/ (accessed Aug 30, 2021).

4 Cousins S. Afghan health at risk as foreign troops withdraw. The Lancet 2021; 398: 197–8.

5 Ahmad A, Rassa N, Orcutt M, Blanchet K, Haqmal M. Urgent health and humanitarian needs of the Afghan population under the Taliban. The Lancet 2021; 0. DOI:10.1016/S0140-6736(21)01963-2.

6 Lancet T. Myanmar’s democracy and health on life support. The Lancet 2021; 397: 1035.

7 Devi S. Tigray atrocities compounded by lack of health care. The Lancet 2021; 397: 1336.

8 Nesamoney SN, Darmstadt GL, Wise PH. Gendered effects of COVID-19 on young girls in regions of conflict. The Lancet 2021; 397: 1880–1.

9 Bowyer JJ, Broster SC, Halbert J, Oo SS, Rubin SP. The crisis of health care in Myanmar. The Lancet 2021; 397: 1182.

10 Aung MN, Shiu C, Chen W-T. Amid political and civil unrest in Myanmar, health services are inaccessible. The Lancet 2021; 397: 1446.

11 Gaffey MF, Waldman RJ, Blanchet K, et al. Delivering health and nutrition interventions for women and children in different conflict contexts: a framework for decision making on what, when, and how. The Lancet 2021; 397: 543–54.

12 Lie JHS. The humanitarian-development nexus: humanitarian principles, practice, and pragmatics. Journal of International Humanitarian Action 2020; 5: 18.

13 Foran S. Challenging patriarchy: gender equality and humanitarian principles. Humanitarian Law & Policy 2019; published online July 18. https://blogs.icrc.org/law-and-policy/2019/07/18/gender-equality-humanitarian-principles/ (accessed Aug 30, 2021).

14 Lancet SIGHT Commission. COVID-19: A Critical Moment to Embrace the Power of Health and Gender for Peace in Conflict-Affected Settings. Sight.nu. 2020; published online Dec 22. https://sight.nu/a-critical-moment/ (accessed Sept 3, 2021).