By Sofia Weiss Goitiandia
As seen through Dalia's eyes:
Reflections on the world of Global Health from a pioneering Sudanese activist - Part 3
In this final instalment of Sofia and Dalia’s interview, Dalia reflects on and synthesises her experiences as an activist in the field of Sexual and Reproductive Health and Rights, both in Sudan and more recently working out of Sweden. She shares her views on what is meant by ‘decolonising Global Health’, and what is needed for this to become a reality, as well as highlighting positive next steps that should be taken in order to eliminate FGM worldwide.
Content warning: this conversation involves discussion of FGM and its potential impacts on affected individuals.
Dalia: FGM is a practice that the community is doing. You can legislate against it – even before FGM was criminalised in Sudan in 2020 (UNICEF, 2020), there were laws against the medicalisation of FGM, so doctors could lose their license for carrying it out, for example (28 Too Many, 2018; Moszynski, 2003). Even then, FGM did not stop, and there were instances of the practice still being carried out in medical contexts (28 Too Many, 2018). So, you really do need that grassroots social change, from and within the community, which no external force can manipulate (Lugiai et al., 2021). You cannot force people to stop thinking that their traditions are valuable. Rather, you need to be having these open conversations with people from those same communities, such that you open up a dialogue with them, and that any eventual change comes from the community itself (Lugiai et al., 2021).
Sofia: Can you give me some examples of what community engagement in this context looks like?
D: It comes in many shapes and forms. First, I do think that medical students and doctors do get a lot of respect from Sudanese communities, who might be more open to listen to them when they explain the harms of FGM. Second, I think involving local religious clerks and having their support that FGM is not a necessary practice in Islam is very valuable. Then I think engaging local activists within the same communities helps too, though it can be difficult for girls and women to share their own stories about FGM openly. I’ve heard very few – probably two – stories of FGM directly in my work. Sometimes I’ve wondered, or felt like, people were perhaps holding back, likely because it’s such a sensitive and difficult topic to talk about. A lot of activism work is also being done with high school students in Sudan too, to try and challenge the norm such that it will be hopefully different by the next generation. Often, we [FGM activists in this context] find that high school students are amongst the most flexible and open-minded; it feels like they can take in the information and genuinely consider it.
S: Do you think that the media or social media might play a role in the relatively greater openness of teenagers towards this topic?
D: I think it might do. Unfortunately, there hasn’t yet been a particularly big social media movement for FGM specifically, but for other feminist causes there have been movements that have been born and have grown on social media platforms (Bajec, 2021; Nugdalla, 2020). The criminalisation of FGM in 2020 did gather some significant attention in the media and social media too, particularly because it took so long for it to go through – the bill has been around for many years, but not implemented, perhaps in part because of the revolution in Sudan and the change in government (BBC, 2020; ReliefWeb, 2020; UNICEF, 2020). But we’ve finally gotten there, and perhaps the new government has helped to make this so. I think they’ve been quite instrumental in a lot of the latest change. Including in some of our own work: we worked with the Federal Ministry of Health in Sudan to get FGM into the medical school curriculum, for example. That was quite a big deal.
S: How do these successes, and the results of your personal activism, make you feel?
D: It’s mixed. I feel happy and proud. I feel like it’s a great thing to do, to work in Sexual and Reproductive Health and Rights, especially in a context like the one I come from – I think the work is much needed. But on the other hand, now I don’t get to do that so much, as I live so far away [in Sweden]. I feel almost a degree of separation anxiety about that, honestly. I feel like I’ve lost something, even though I’ve found my place in other organisations, and am pursuing a career in Global Health. This is kind of ‘filling that void’, but I’m always going to have a soft spot for the issues that it all started with for me. It’s also been very interesting working with organisations that are Western-based – the issues are quite different.
S: I can imagine. I often realise quite how clueless I am, for example. As much as I’d like to talk or think or tackle certain issues, I realise – even speaking to you – how inappropriate it would be for me, for example, to be doing the work that you did in Sudan. I wouldn’t be the right person for that.
D: I’ve had to learn a lot, during the process of working with different organisations based out of varying contexts. In Sweden, I’ve been working with an organisation as a Director of External Relations. Here I get to help, but also to learn. For example, even the vocabulary of documents like an organisation’s Code of Conduct is quite different, believe it or not. And I’ve found it quite fulfilling to learn about these differences and nuances. Ultimately, I would like to work on issues that do not exclusively affect one country, and I’m not fighting only for one cause. Rather I’m interested in all the issues that fall under the umbrella of Sexual and Reproductive Health and Rights. In that context, it has been an enlightening experience for me to do work that is in some ways similar to how I was working with WHO or the Ministry of Health in Sudan, i.e., external relations, and that yet at the same time exposes me to how organisations’ missions, work values and priorities are different. And the fact that we talk about topics like decolonising Sexual and Reproductive Health and Rights [where I am working] now is amazing to me. We never talked about that back home in Sudan – or at least, I was not exposed to that. I thought about it, I felt it, but it was not something that we talked about openly in our work. I’m not sure why. But lately I’ve been exposed to the notion that external actors can support communities, but that the changes themselves have to come from within communities. This was my exact thinking back when I was engaged in activism in Sudan, but I didn’t have a word or concept to describe it with yet.
S: What then does decolonising Sexual and Reproductive Health and Rights mean to you?
D: It means a lot of things. It means to begin to question, for example, organisations that are working on eliminating FGM but are run by people from communities not affected by FGM; or organisations that are based in countries that don’t have FGM; or the recruitment of experts exclusively from European countries to work in countries that are affected by FGM, when the country already has a lot of knowledge, experience and capacity. It makes me think that people in these countries [affected by FGM] would know the issues and have the ability to address them, maybe more so than others who have not been so widely or directly exposed to this issue. And their work can be supported by groups such as those I’ve just mentioned, without these uniformly taking over the work.
S: It seems quite clear that the people for whom FGM is a practical reality would be better placed to address it than someone from a different country where FGM is not a prevalent public health issue who has perhaps read about it. It’s not to say that this latter person can’t support or contribute or do something, but perhaps they’re not the right person to lead the efforts against FGM in a given country. At least not as a systematic strategy used most of the time.
D: Exactly. And then it’s not only FGM. A lot of Global Health priorities and agendas are set by people in countries that are not particularly affected by the issues in question (Okegbe & Ifafore-Calfee, 2021; Ollila, 2005). This has consequences – for funding as well as the investment of other kinds of resources into different issues, for example (Okegbe & Ifafore-Calfee, 2021; Ollila, 2005). It’s especially problematic when the priorities do not always correlate with what affected communities would themselves prioritise as most important. For me, this is a key issue at the heart of the discussion about decolonising Global Health.
S: It is one of those issues that does feel so clear when I hear you speak about it, and yet I must admit I’ve struggled too with my own positionality in it. This is because I would like to be involved in this space, but I’m quite aware that in my own desire to ‘do good’, there is quite a high risk of doing harm.
D: I think it is a fine line to walk. I wouldn’t want people to shy away from trying to help – we all recognise, for example, that FGM is a human rights violation (World Health Organisation, s. d.). And we live in a world that is very much globalised, with people moving everywhere. So, you might encounter an FGM survivor, in a medical capacity, or as a friend. Or you might encounter and learn about issues or challenges to health that are happening in other countries that are not your own. So, it is good to be aware, first of all. And then second, I would urge people to find a way to help that is appropriate. There are ways, even if they require exploration and a good deal of reflection. Above all perhaps, we need to make sure that we’re asking communities what they need, and then that we’re listening to and acting upon their answers. People who are not in the situation or local context in question will not always know best or be unbiased. So, its invaluable to have those perspectives from within the community to guide any efforts, and to show external individuals who want to help how they can be allies and how to support.
S: Do you have any concrete examples for how people can get involved?
D: People coming from communities affected by FGM who are interested in working within this topic should absolutely do so. So much can be done through community outreach to sensitise diverse communities and raise awareness about the harms of FGM; and these are actions that in turn can effect social change and even apply pressure to governments to criminalise FGM (Lugiai et al., 2021). This is critical as FGM is still legal in a number of countries (Equality Now, 2019). Then, individuals coming from communities that are not affected by FGM can still also participate, for example, through supporting local organisations in FGM-affected communities – and I say affected communities because I don’t just mean highly-affected countries, because there are also affected groups of (for example) migrants or refugees in countries that are not overall ‘epicentres’ of FGM (Barrett et al., 2021; UNHCR, 2013). This support can look like donations, raising funds, offering support logistically and through advocacy, as well as lobbying – particularly to criminalise FGM. I think it’s very important to pressurise governments to express their support for ending FGM, and members of the public can contribute to that. Further, I think that all students and professionals within the medical field should especially be aware of FGM, and how to address its complications. Not only in the countries most affected by FGM, but worldwide, since in the context of globalisation medical professionals in almost any country could encounter FGM survivors. They should be able to provide appropriate care and support, as well as advocate for its prevention.
S: What would you see as the next step forward in the context of addressing FGM from a global health perspective?
D: The target is no more FGM anywhere in the world. We’re trying to eliminate it. While the situation is getting better and the prevalence is going down in many countries, this change could be faster. But it needs to come from communities deciding for themselves to abandon the practice. This is how FGM will be eliminated. I’d say that international support is still important and should be in the form of supporting local activism in FGM-affected communities, who can work towards changing the social norms around FGM. Then there are many conventions, such as the United National Conventions on the Rights of the Child, which is one of the most ratified conventions that has ever existed. It calls on states to provide legal, educational, health and institutional measures to safeguard children, and article 19 specifically is relevant to protecting children from FGM (End FGM, 2016; UNHCR, 1990). And there are several other treaties and conventions that recognise FGM as a violation of human rights, so I think that governments should be pressured – possibly by international monitoring bodies – to adhere to these conventions and treaties designed to protect children (UN Women, 2011). Further, the WHO has, for example, a clinical guideline for doctors caring for patients who have undergone FGM (WHO, 2018), and I think there should be guidelines, tools, training and policies to ensure the adequate provision of medical care and counselling for people living with FGM, as well as for the prevention of the practice. So, there is a lot that can and should be done from different angles. Ideally, all of these angles will be worked on simultaneously.
S: There’s a lot that needs to be done, but it feels like there is a clear goal, as well as a lot that all different kinds of people can contribute.
D: Absolutely, there’s a lot of space to make a difference towards ending FGM once and for all.
S: And just one final, more personal question – do you have a personal mantra that inspires you? What drives you in your work?
D: I think what motivates me the most is the fact that health inequity still exists. It drives me to want to work from a broader perspective. This is even driving me further now into wanting to work in health policy, because then I can keep vulnerable populations – including women, children, minorities and refugees – at the heart of it. And I believe they should be at the heart of decisions and the design of programmes. To want to work with these groups is something that I think I will carry forever. And it comes from being from a country where the medical system is under a lot of strain, and there is still a lot of inequity in access to healthcare. So maybe the mantra is ‘health for all’ – including the vulnerable; especially the vulnerable.
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