A very narrow view of the world

Revisiting how approaching our work from a Western, high-income perspective can shape how we think and what we do.

I try to be alert to my biases when I think, write, and act. As I have written before, our biases inform the questions we ask about our health, pointing to answers that then inform action. One feature of thinking about one’s biases is the recognition this brings of having even more biases than one originally considered—more, perhaps, than anyone can fully reckon with. Social and occupational status, personal identity, our talents and lack of them, our virtues and shortcomings all constitute the lens through which we see the world. They are the water in which we swim. Just as water is to the swimmer so ubiquitous that they can forget they are in it, our biases are so ubiquitous that they can shape much of what we do and think without our being fully aware of them.

This makes it important to continually revisit our biases, in the interest of keeping them in perspective so that, even if we can never fully step outside of them, we can at least remain aware that they are there, an inextricable part of how we see the world. Addressing our biases is also core to building and maintaining the public’s trust in what we do. If we allow ourselves to become out of touch, unaware of the biases that shape our view, we are less likely to be seen as trustworthy, engaged partners in the work of promoting health, alienating us from the public. This alienation works both ways. When our vision is clouded by bias, it is harder to see the person standing in front of us, harder to understand their perspective, or what is most supportive of their health.

Today, then, I would like to revisit a bias I have talked about before, but which is arguably still underdiscussed in the broader conversation about biases: the bias of living in the Western (for want of a better term) high-income world. It is a world of tremendous privilege compared to the conditions in which many others around the globe live. It embeds many unseen advantages into the daily experience of those who live in this world, with implications for how we prioritize what matters most for health.

The presence of this bias poses a challenge for those who work in health to genuinely ask what can support the health of all, not just what looks best from our privileged perspective. This means first understanding the factors that reinforce this bias, so we can better understand the water in which we swim towards occasionally coming up for air and seeing the wider world and what it demands of us in our work for healthier populations.

Let us start with some numbers. I live in the US, a country of about 336 million people. That is about 4.23 percent of the world’s population. It is important to remember that, while the US in many ways punches about its numerical weight in its global cultural influence, the people who live here are a fairly small percentage of the global population. This reflects the comparatively small percentage, globally, of people living in the high-income world. Of the eight billion people in the world, about 16 percent are in high-income countries. This means that about 84 percent of people in the world live in middle- and low-income countries. As anyone who has traveled outside the high-income world knows, the differences between these regions are significant, perhaps nowhere more so than in their implications for health. Our health is shaped by the air we breathe, the water we drink, the food we eat, and the spaces where we live, work, and play. All these factors, and more, intersect with the economic and social resources of a given place. When these resources are abundant, a place is on its way to being optimized for generating health. When they are lacking, a region can set the health of its population up to fail. For much of the world’s population, the conditions of life are likelier to generate injury and disease than health. It is necessary to bear this, always, in mind if we are to establish correct priors for the work of creating a healthier world.

Let us now add another element to our consideration of this bias—language. Although it is my second language, I speak English (I think fluently). I am comfortable with the language and assume that I can get by in it, or in several other languages I have learned, anywhere in the world. Yet English is not just any language. It is the global language of science, the field where I make my living. It is also widely spoken in the Western world, allowing me to move with ease between countries and capitals which are the seats of much global influence. I can also express myself in my writing with greater ease than someone who must laboriously translate their thoughts into the lingua franca of their field. As one of approximately 1.35 billion English-speakers in the world, then, (including about 241 million speaking only English in the US), I have an advantage over the rest of the global population that does not share this knowledge, an advantage which should inform my perspective about the privileges I enjoy and the biases they shape. 

So, what do these biases mean for how I see and interact with the world? First, they mean I experience far less daily hardship on the core elements of day-to-day living than do most of the world’s population. I can imagine doing things efficiently, getting from A to B relatively smoothly, with working Wi-Fi, with the expectation of water in taps, clean bathrooms, and the other benefits of the reliably functioning infrastructure we tend to take for granted in the high-income world. I devote very little time to the foundations of Maslow’s hierarchy of needs—finding food and shelter—allowing me to try to contribute through my thinking and writing. It is all fine and good for me to say “I work hard to make this contribution” but I can do this because, well, I do not have to worry so much about finding fundamentals. Those of us who enjoy this luxury would do well to remember that is indeed a luxury, one that is not shared by about one in seven of the world’s adults.

Second, I have an easy path to communicating my science through language, through the unearned advantage (in my case obtained through migration, but still) of comfort in a language that is the global tongue of science. There is no good reason for this (the preeminence of English owes much to the history of colonialism), but it is still good luck for me, and for everyone else who speaks this useful language. One could well ask: why should global science not be communicated in, say, Mandarin principally, meaning that I would need to learn and edit my work in Mandarin? This question reflects a wish to see a world that is both fairer and not the one we are currently living in. This reality, unfair as it may be, means English speakers in a range of fields simply have it easier than non-English speakers. This calls on us to look beyond our privileged view of the world to ask: what challenges emerge in terms of one’s potential if one easily emerges into a world that is larger than oneself? How do language barriers obstruct professional and personal achievement? What about health achievement? I ask these questions without ready answers to them, in the spirit of having conversations about what we may be missing, overlooking, because of our biases.

Finally, my biases mean I see the world and its problems through the lens of being able to think and express myself in a Western, high-income context. I live in a democracy, deeply flawed, but at the end of the day one with an ethos of free speech and civic engagement. While I have at times tried to push controversial ideas, I have never worried I will be arrested for what I write, yet many in the world do have this worry, lacking the protections of the First Amendment. Neither do I think as much as I perhaps should about fundamental challenges to health that many in the world face—lack of access to clean water, for example, or to avenues for achievement and the development of potential. I do of course think about these challenges, but not to the extent that their scope demands, a scope which it is easy to lose sight of from the perspective of my biases.

Why do I write all this? I write this because it seems to me that while we talk a fair bit in health about privilege, that conversation has grown almost entirely within the Western world, with relatively little of it grounded in a global comparison. While scholarship in global health has concerned itself with this, largely through concerns about authorship, it has not contended with a more foundational imbalance in the water we swim in, and with how much harder it is for the many who must swim upstream all the time, as much of the world does.

It is worth noting, of course, that my analysis of this bias reflects, in a way, the bias itself. I have suggested certain criteria for what does and does not support my Western conception of a healthy life. But I am hopefully not so narrow in my view as to not realize that joy and fulfillment are not necessarily indexed by Western or non-Western identities, that there are billions of happy self-actualized people with fewer of what I would call “privileges.” But it is also clear that any success one has when grounded in a context of ubiquitous advantage is scaffolded by that advantage. Those of us living and working in a richer world must acknowledge, then, that this perspective informs all we do and think.

What to do about this? In the context of this piece, I simply want to highlight a bias that informs how we operate and how we think. There is a growing philosophical tradition concerned with how one lives with advantages, and I leave the development of this to people who are sharper in their thinking than I am on these matters. But it seems right to remind myself, and us, how this influences the questions we ask, what we choose to write and talk about, to support a focus on the questions that matter most for the health of the many.

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Also this week.

Special thanks to Michael Stein for joining The Source to speak with David Martin Davies about our book, The Turning Point: Reflections on A Pandemic.