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What About Us Inbetweeners?  Navigating Identity and Inclusion in Global Health

By guest contributor Rupal Shah-Rohlfs

As a woman of colour embodying diverse roles and identities—akin to the creative, sustaining, and transformative energies of female Hindu deities—I find myself awkwardly positioned in global health. Whether in seminars, trainings, or meetings, with my roots spanning Kenya to Gujarat and lived experiences across the UK, Germany, and South Asia, I don’t seem to comfortably fit into dichotomous categories like ‘Global North’ and ‘Global South’. I am not British, Indian, or European enough. The complexities of global identity are personal for me.

Madhukar Pai’s compelling article about double agents in global health struck a chord with me, even though I often feel more like a triple agent. After hearing Pai’s keynote address at Yale School of Public Health, I identify more as an ‘Inbetweener’ in global health. This term captures the valuable insights we ‘Inbetweeners’ offer. As the daughter of immigrant parents who were born in Nairobi, Kenya, during British colonial rule and later migrated to the UK, I am influenced and shaped by varied socio-political ideologies in London—including the East African Indian diaspora community, a constituency led by Thatcher, and a multicultural all-girls non-elite school. Drawing from my educational background in pharmacology, clinical pharmacy, and international public health, as well as immersing myself in varied urban settings like Bath, Dhaka, Heidelberg, Pune, Nairobi, and London, I bring a nuanced insider-outsider perspective to global health discussions.

While I don’t speak about social movements, my identity as part of the British ethnic minority and the globally underrepresented Jain community influences my insights. In this piece, I aim to use my position—Indian by heritage, British by birth, and a German resident through love—with formal and informal training in the arts and sciences to explore how those of us caught ‘Inbetween’ various worlds, whether in jobs, research, social identity roles, or physical spaces, can drive transformative change while navigating constant transitions and daily uncertainties that shape our identities.

Ever felt like you’re floating between worlds—not just during a crisis, but in everyday life? That’s the ‘Inbetween’ experience. For someone like me, it’s not temporary; my identity is constantly merging, disintegrating, and reforming. This underscores the importance of knowing ‘who I am’ in my field. This clarity directs our values, goals, and norms. I relate to Girija Sankar’s experiences in The Lancet: “As a non-native South Asian in a high-income country working in global health, I rarely run into people like me.” Sankar highlights epistemic ‘inner circles’—a concept aligning with my observations of the narrowing of identity and capabilities in our field.

Currently, I live and work in South Germany, in a setting where finding someone with my confluence of cultures is uncommon. In this global health landscape, I have thrived within multidisciplinary teams as multifaceted as the continents themselves, and I am grateful for the supportive colleagues and mentors in both academic and non-academic settings. However, I feel that our collective efforts to connect with people from different regions are often hindered by the unintentional but limiting divisions between areas labelled as the ‘Global North’ and ‘Global South’. My multi-layered background lets me navigate between these oversimplified terms, leading me to question if they cause more conflict than collaboration, even if we trust our audience and/or collaborators to know the difference.

Now, throw in the mix challenges like escalating economic disparities, geopolitical dynamics, funding shortages, and climate change, and it’s clear why the old staples—stable jobs and institutions—don’t anchor us like they used to. Being an ‘Inbetweener’ in the academic gig economy, I really feel these shifts. And here’s the kicker: critiquing global health science feels almost taboo. It shares a deep-seated moral foundation with medical humanitarianism and is committed to ‘saving lives.’ Therefore, criticising the methods and tools used to enhance health in lower-and lower-middle income countries may appear somewhat trivial. But is it really? I was comforted when I watched Stella O. Babalola, give the Dean’s lecture at the Bloomberg School of Public Health. She highlighted her current efforts to make the Ideation model (a health communication model) more relevant to Africa and Asia by incorporating non-Western theories of behaviour change.

As an emerging researcher with an interest on person-centred care and user-centric research, I understand the significant role that empathy and equity play in enhancing both patient experiences and the value of co-designed interventions and tools. On the Global Health Matters podcast, Tom Wein outlines three pathways to dignity in designing global health programmes: agency, representation, and equality. My background as a second-generation immigrant from London, combined with extensive work assignments and field experiences, has sharpened my ability to empathise with patients, stakeholders, and colleagues from diversely different backgrounds. This hands-on experience enhances my ability to collaborate in global health. Bridging cultural and socioeconomic gaps is crucial for establishing effective and respectful leadership and partnerships, which are currently imbalanced in global health cooperation and science. Evidence suggests that teams with manifold perspectives are not only more cohesive but also pay closer attention to local complexities. How can we move beyond terms like the ‘Global North’ and ‘Global South’ to foster more inclusive and accurate discourse?

I am still exploring what it means to be a British-Jain-Indian-European woman with links to Kenya in the field of global health. Amartya Sen argues that our identities extend beyond our histories in his book ‘Identity and Violence – The Illusion of Destiny’. There are a great variety of categories to which we simultaneously belong. I can be, at the same time, an Indian, a British citizen, a Gujarati with Gujarati ancestry, a second generation Indian East African, a German resident, a public health scientist, a pragmatist, a still life artist, a dabbler in photography, a strong believer in secularism and democracy, a woman, a feminist, a defender of animal and human rights, with a non-religious lifestyle, from a Jain background. Belonging to these groups varies in importance depending on the context. Each day offers an opportunity to define this pluralistic identity. How can others with similarly complex backgrounds leverage their perspectives in global health for social and political change?

As we contemplate the future of global health, let’s welcome the ‘Inbetweeners’ to the table not as misunderstood anomalies but as nuanced voices that connect different worlds, forging alliances across boundaries, and promoting genuine collaboration. If you find yourself between categories, feel free to share your story. You don’t need multiple layers to feel like an ‘Inbetweener’. All human experiences—love, home, family, loss—are universal. It’s important to remember this without disregarding identity or reducing individuals to boxes.

Let’s continue this conversation—as we strive to create an environment that truly embodies the ‘global’ in global health in our beautiful interdependent world.

About the author:

Rupal Shah-Rohlfs has a diverse academic background in Pharmacology, Clinical Pharmacy, and Global Public Health. Since she started at the Institute of Global Health at the University of Heidelberg in 2021, she has been involved in research to practice, and evaluation and implementation research. Capacity building is at the heart of her work, and she has been involved in programs that expand education and research capacity in West Africa since 2020. Connect with Rupal on LinkedIn to share stories and continue the conversation on identity and inclusion in global health

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