The Use of Imagery in Global Health: An Analysis of Infectious Disease Documents and a Framework to Guide Practice

"The images one chooses to tell the story of global health need to be thoughtfully chosen and presented, particularly in relation to imbalances in power, gender, race, economics, and culture."

Global health photography functions to represent the reality of global health programmes and their beneficiaries. Its primary purpose is to authentically inform rather than to construct fictional narratives that can misrepresent the real experiences of the individuals depicted. This type of photography has secondary uses for organisational marketing. This article reviews imagery included in public-facing grey literature related to vaccination and antimicrobial resistance by global health actors headquartered in high-income countries (HICs). The goal is to offer insight into how imagery use can be made equitable, respectful, ethical, and relevant.

Documents were considered for inclusion if they were published between 2015 and 2022, available in the public domain in English, and included at least one image. For vaccinations, the keywords were: vaccin; vaccine; vaccines; vaccination; vaccinations; Immuni; immunisation; immunisations; immunization; and immunizations. The antimicrobial resistance keywords were: antibiotic resistance; antimicrobial resistance; bacterial resistance; and antimicrobial resistance.

A total of 1,115 images were gathered across 118 reports, sourced from 14 global health actors. Of these images, 859 (77%) had identifiable people present in the image. Healthcare professionals were depicted in 370 (33%) images, adult non-healthcare professionals were depicted in 402 (36%) images, and children were depicted in 393 (35%) images.

The analysis highlights the biased approaches in the use of imagery by those who hold power in global health. The narrative depicted in this imagery is one of power imbalances driven by race, geography, and gender - e.g., depicting women and children from low- and middle-income countries (LMICs) with less dignity, respect, and power than those from HICs. The absence of evidence of consent for using intrusive and unnecessary images, particularly of children in LMICs and often out of context to the narrative of the reports, is of particular concern to the authors.

Following this analysis of imagery use along four major themes (relevance, integrity, consent, and representation), the researchers present a framework for the future use of imagery in global health (see figure 2 in the paper). They proceed to describe the key findings under each theme, providing examples of images in figure 2. Key points include:

• Theme 1: Relevance to the stated purpose or content of report - Determine the key emphasis or focus of the photo, which might be the people being photographed or the action they are performing. It can be analysed through the focus of the lens, the angles of the photo, the positioning or eye contact of the individuals depicted, etc. Example: The front cover of a report shows an image of a child who has been vaccinated against polio and happily shows off the ink sign (marking) on her fingernail that conveys this.
  • Sample tip: Identify the location where an image was taken to help the reader differentiate between countries and health programmes instead of making generalisations about diverse geographical regions covered within a report.
• Theme 2: The need for consent - Assess whether there is any clear evidence to indicate the capturing of the photograph was done consensually; this can be a written statement somewhere within the document or a visual indication from the photo (e.g., posing, eye contact). Example: Photographing women in one image from behind, rather than face-on, protects and anonymises them.
• Sample tip: Seek explicit consent when photographing sensitive scenes that depict individuals exposed, vulnerable, or suffering, especially when images are of children. Confidence that the right to consent had been observed was particularly high in cases when the individuals photographed were named.
• Theme 3: Imbalances in representation by race and gender - Consider imbalances in the representation of people by their race or gender, either through the frequency at which some racial groups or genders are portrayed or the way these groups or gender have been represented. Example: Balanced representation of workers and people native to the region in one publication - women are shown in positions of authority, and no one group is being pushed forward as particularly vulnerable or in need of pity.
• Sample tip: Avoid conveying power imbalances between healthcare workers and healthcare recipients by considering how different parties are depicted in terms of expression, posturing, and positioning in the frame.
• Theme 4: The integrity and dignity of individuals in images - Assess the degree of professionalism (seen through the setting (e.g., conference or clinic), but also the clothes or uniform of the individual), dignity and privacy (can be compromised if the individual is captured in a sensitive or negative emotional moment), and emotion (the use of emotionally evoking scenes, e.g., images of individuals in distress or in conditions of poverty) with which individuals are portrayed. Example: The face of the child in one image is covered - dignity has been considered and preserved through maintaining privacy and avoiding needless displays of distress and vulnerability.
• Sample tip: Keep in mind that, although staging can be useful and respectful, it also serves storytelling agendas that are harmful to the dignity of the individuals depicted (e.g., in the case of images of children depicted alone in poor conditions to provoke pity).

The framework articulated here may provide a platform for global health actors to redefine their intentions and recommission appropriate images that are relevant to the topic, respect the integrity of all individuals depicted, are accompanied by evidence of consent, and are equitable in representation. The authors have created a simplified version of the framework as a checklist (see pages 10-11 of the appendix, which also provide examples of "good" images and problematic ones, with explanations). "Adhering to these standards will help avoid biases that lead to insensitive content and misrepresentation, stigmatisation, and racial stereotyping. Upholding such ethical standards will also help realise the potential for empowerment and advocacy provided by photography."