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Photography is a powerful tool in storytelling and scientific communication. But it can also cause harm when used unethically.

We started to realize how photographs can send the wrong message when we were approached, as a group of infectious disease specialists, to develop a presentation on resistance to antibiotics. Our audience was a clinical group in east Africa.

The global health organization that asked us to do this wanted to use its own branding on our teaching slides. But when we got our slides back, we found the organization had used an image of black African women in traditional outfits looking like they were dancing and holding white candles. Confused, we pointed out that the photograph wasn’t relevant to our work. We were told this was standard imaging verified for use in global health within the organization.

One of our colleagues pointed out that the image was of women in Nigeria going to church. We wondered whether an image of nuns would have been used for a health presentation to a European audience.

After speaking about this experience with colleagues from different ethnic backgrounds, we decided to look at how people are represented in global health literature and publications about antibiotic resistance and vaccination.

What we found was evidence of power imbalances in race, geography and gender. Through the choice of images in publications, women and children of color in low income countries were treated with less dignity and respect than those in high income countries. Evidence of consent for using intrusive and unnecessary images was absent. And often the images were used out of context.

We then tried to suggest some guidelines for using images more appropriately.

No ethical guidelines

The first step was to find out whether the use of photographs of people in global health was subject to any ethical standards or guides. We found guidelines from Photographers Without Borders, European Non-governmental Confederation for Relief and Development (CONCORD), levoxyl and sperm count Code of Conduct on Images and Messages, and the National Press Photographers Association—but no standards specific to health. This is a critical gap.

While the concept of patient confidentiality is closely guarded in many countries, global health seems to slip through the net of regulation or guidelines. For instance, taking candid photos of patients, especially in health care settings, is strictly prohibited for research- and health care-related activities. Any such practices must be subject to strict ethical review processes and informed consent.

But the regulations are not applied equitably or universally.

Our evaluation of images of people used in global health looked at four aspects: relevance, integrity, consent and representation. We included in the review photographs of people that had been featured in publicly available documents from global health actors published between 2015 and 2022.

In over 118 reports from 14 global health actors, there were 1,115 images. Of these, 859 included people. We found an over representation of people, including women and children of color, in the images used. Two out of every three images were of people of color, and for children this increased to nine out of every 10 images. Images that depicted people of color were predominantly representing countries in the global south and were candid images of real life and often in health care settings. There were images of adults and children receiving healthcare, some in distressed situations or while receiving medical examinations. In contrast, images used from the global north depicted sterile settings, were often staged, and included actors.

Overall, we found representations of people of color and women and children from the global south to be more likely to be represented in ways that were inequitable and unethical. The persistent use of intrusive images was of particular concern.

Why does representation matter in global health?

In the field of infectious diseases, global health and tropical medicine emerged as disciplines to protect white colonizers from the tropical climates and communicable diseases of the countries being colonized. Thus, historically, imagery in global health has also suffered from telling a story of diseases, war, famine, and poverty, to generate sympathy or funds for research and development.

Photographs are powerful in the imprint they leave in the collective psyche. There are ethical responsibilities in how we capture, contextualize and distribute photographs of people. Global health photography has a different purpose from journalism. But the lack of ethical standards or guidelines has blurred the distinction.

For example, recently the monkeypox outbreak in the north was visualized using black skin. And images of child victims of war and rape captured by Médecins Sans Frontières found their way into stock image libraries for sale.

Current practices in use of photographs of people in global health run the risk of perpetuating attitudes that are rooted in colonialism and reinforcing racial stereotypes. They can reinforce “white savior” narratives, shaming, cultural appropriation and cultural exoticism.

Developing guidelines

We have developed a framework to assist those who wish to visually represent people in global health within the boundaries of accepted standards. The aim is to:

• assure the relevance of the images depicted

• uphold the right to dignity and privacy of subjects

• provide a mechanism for transparent consent in participation of subjects in the photograph and its subsequent use

• ensure equitable and accurate representation of individuals and serve to counter stereotypes.

Recognizing how powerful and necessary imagery is, we urge all readers to view this framework and join the conversation to find a more ethical and equitable representation of health and illness that does not discriminate against people according to race, gender, geographic, cultural identity and age.

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