Invited, refused, absent
Global health wants frontline nurses, just not at its conferences
We held an event on Monday; it went really well, and we got a great turnout with lots of buzz. Sadly, there was one element that didn’t go to plan. One of our keynote speakers was refused a visa and thus had to present online.
The keynote at this event was to form part of a trip that would have been invaluable for all concerned. Yet despite our best supportive effort, the visa was refused.
Initially I put this down to bad luck, the wrong person considering this on the wrong day. But then, when I mentioned it to people in my orbit, everyone had a story to tell.
So, I started digging, and what I found is worse than I had ever imagined.
Last month the International Confederation of Midwives held its Triennial Congress in Lisbon. The theme was “One Million More Midwives”. More than 3,000 midwives, researchers, educators and policymakers gathered to discuss maternal and newborn health: the 260,000 women who die each year in pregnancy and childbirth , and the 4.2 million babies who are stillborn or die in their first month. Nearly all of those deaths happen in Africa and South Asia , Sub-Saharan Africa alone accounts for around 70 per cent of maternal deaths worldwide.
At least twenty invited speakers from Africa and Asia were refused entry at the last minute. Many more delegates may have been caught in the same net. The refusals fell on midwives from Nigeria, Ghana, Rwanda, Burundi, Uganda, Ethiopia, Sierra Leone, the Democratic Republic of the Congo, Bangladesh and India. These were leaders, researchers and educators, formally invited, several with presentations already accepted into the programme .
Harriet Akello directs midwifery for Mother Health International, which works in remote communities in Uganda. She was due to run a session on how evidence-based guidelines keep women and babies alive in the hardest conditions. She applied months in advance, but her visa was refused the Thursday before the congress opened.
An Ethiopian assistant professor, selected by ICM for its leadership sponsorship programme, was refused over her bank statement and what the consulate called an unreliable purpose of travel (the same reason we were given for our keynote speaker). Two delegates from the Bangladesh Midwifery Society were also refused. They are the people who persuaded their government to hire five thousand more midwives. In a congress about one million more midwives, they had a right to be in the very front row.
In case you are wondering, yes, it seems every delegate from a wealthy country got in without an issue.
There is a particular kind of global health absurdity in holding a conference about the world’s shortage of midwives, then refusing visas to midwives from the countries where that shortage is most evident.
Four years ago, Canada hosted the International AIDS Conference in Montreal. Canada rejected 1,020 visa applications for the conference (36 per cent of the total) and left another 10 per cent unprocessed by the time it ended, so effectively closer to half. The rejection rate for applicants from Nepal was 83.5 per cent; from Nigeria, 55.8 per cent; from Cameroon, the DRC, Ethiopia and Ghana, over 40 per cent.
Activists took over the opening ceremony and the president of the International AIDS Society called it global inequity and systemic racism from the stage. Canada’s immigration department later reviewed its handling of the conference and found no fault. When the International Council of Nurses brought its own Congress to Montreal the following year, Canada’s official guidance made the same point more honestly: a special event code had been assigned for visa applications, but it did “not offer any advantage to the applicant”.
The asylum fallacy
Aha! But some of these people claim asylum; scream the usual crowd. It’s true, there is no point denying that this happens in a very small number of cases, but without widening this post to the length of a book, I think this points more to the failure of ‘safe and legal routes’ than to the character of the people applying who are dedicated health professionals and experts in their fields.
Migration is very often driven by failures within the health systems people are leaving in the first place: weak health services, poor pay and limited career development are the classic push factors that lead health workers (and everyone else!) to look abroad. Conferences and international collaboration are among the few mechanisms that work in the other direction, strengthening the workforce and the system at home rather than depleting it.
Making it harder for health workers to attend those conferences does not close off migration. It closes off the exchange that might have reduced the need for it. Frankly tarring everyone with the same brush is deeply cynical and counterproductive. The benefits completely outweigh any perceived risk, even if you happen to view a nurse claiming asylum as a risk.
It would be comfortable, from London, to treat this as other countries’ bureaucracy, but this isn’t the case at all.
In 2018, at least seventeen researchers fourteen from sub-Saharan Africa, three from Asia, were blocked from attending the Women Leaders in Global Health conference at the London School of Hygiene and Tropical Medicine. Heidi Larson, director of the school’s Vaccine Confidence Project, called the refusals discrimination and read out letters from the absent on stage .
The following year, twenty-four of the twenty-five researchers invited to the LSE Africa Summit were refused visas. Seventeen delegates were barred from the European Conference of African Studies. At a Wellcome Trust meeting on Ebola preparedness for the Democratic Republic of the Congo, a £1.5 million flagship programme, convened while the outbreak was live only six of the invited participants could attend. Seventy senior leaders wrote to the government in protest. Sierra Leonean academics invited to LSE events waited weeks for refusals that arrived without explanation, or received their visas after the events had ended. LSE began moving conferences to Belgium. A pandemic-preparedness meeting the host country’s own scientists could not fully convene, four months before anyone had heard of COVID.
The international president of Médecins Sans Frontières said her organisation faced the same problem constantly: staff from Africa and the Middle East invited to MSF’s own general assembly simply never make it, to the point where MSF now issues invitations a year in advance.
The refusal letters themselves are something else. One professor was refused because he had not previously been sent on similar training in the UK. A senior Ugandan researcher was told there was no evidence he would benefit from his trip. A consular officer, ruling on whether an epidemiologist would benefit from an epidemiology meeting.
The structure below the surface
In a twist that will surprise none of you, the Royal Society found the highest refusal rates for UK visas similarly skewed towards the global south. The gradient is not subtle, and it maps almost exactly onto the gradient of disease burden. Sub-Saharan Africa alone accounts for roughly two-thirds of all people living with HIV worldwide . The countries that carry the most maternal deaths, the most HIV, the most epidemic risk, are the countries whose health professionals find it hardest to be in the room.
It starts early. (In 2017, every medical student from Kenya, Uganda and Tanzania who applied to attend the International Federation of Medical Students’ Associations meeting in Montenegro was rejected. The exclusion is not just of today’s workforce but of the next one — the students who would have built the networks that careers in global health are made of.
Voice still needs a visa
Global health loves “voice”, “representation” and “lived experience” and it builds whole panels around those words. But voice still needs a visa and representation still needs a passport that works in the manner intended.
Lived experience still needs an embassy official to believe you.
The visa system is global health’s invisible gatekeeper as it decides who gets to be “global”, who presents evidence, who networks, who gets remembered by donors and policymakers, and whose experience remains conveniently local.
Nurses and midwives make up the largest share of the world’s health workforce, and the shortage of both, an estimated 900,000 midwives alone is concentrated overwhelmingly in Africa and low-resource settings. The people working inside that shortage are precisely the people the system finds easiest to exclude. Global health does not only exclude people by ignoring them. There is a particular cruelty in inviting people to share expertise only for your government to refuse them later.
Often there is no right to appeal.
What gets lost
A conference can survive missing speakers. The programme runs, the coffee gets drunk, the social media posts get written.
But what gets lost when the people working closest to the world’s heaviest burdens of illness and death are not there to shape the conversation, the interventions that get funded, whose evidence counts, which model of care gets exported back to the very countries whose experts were kept at home.
A global health workforce movement cannot be global if the nurses and midwives most affected by the crisis are the ones most easily excluded. Until the machinery of travel matches the language of inclusion, global health will keep losing the insight it cannot replace.