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WiL – GH Series: How to ensure the narrative stays local – supporting colleagues in lowe

Women in Leadership – Global Health Series: How to ensure the narrative stays local – supporting colleagues in lower income settings

by Lesley Crichton

When we were 11, my best friend Lisa wanted to make a birthday cake for her mum. I love baking, so I went to her house to help. I, the elder by 8 months, led the show – I chose the type of cake, gave out instructions. I left that afternoon feeling pretty good about the day – we’d made a lovely cake and I knew Lisa’s mum would be pleased. However, later on, Lisa’s mum phoned to say that while she appreciated my efforts, Lisa had felt like I had taken over a bit too much, and that she was now going to make another cake – a flavour she knew her mum preferred.

Over the years, I have learned that, as someone from a high-income country, leadership whilst working in a low- or middle-income country (LMIC), is a bit like making that cake. But with some self-awareness and thought, it is possible to work together to make a cake that Lisa’s mum would want and deserve.

There is a long history of people from high-income countries going to support projects in lower-resourced settings, usually in Sub-Saharan Africa or Asia. These projects are often funded by the west, thought up by westerners, and in some cases can really perpetuate old power imbalances caused by colonialism, control and agendas. But how can we, as well-meaning westerners, ensure we are supporting local people to lead the way and not subconsciously advancing our own agendas?

I like to ask myself why I, a consultant anaesthetist, decided to move from Scotland to Zambia, with my husband and three young children, in 2017, to lead a young training programme in anaesthesia. In reality it was for a whole host of reasons – a desire to help (in the white saviour sense, at least a bit), a bit of wanderlust, a chance for the children to experience life growing up in Southern Africa like their dad, and to be a bit closer to his side of the family. And a real sense that I would learn so much more than I ever could be staying at home.

What hit me when I got there, very quickly, was the unfairness of it all. How I had access to places and people because of the colour of my skin. I noticed many subtle, unintentional ways that the agenda was dominated by me and the high-income half of our Zambia/UK partnership.

Two of the things I noticed…

  1. Power imbalance matters – in the same way that my eight months of seniority mattered to two 11-year-olds making a cake. Others would be too shy or respectful to speak up or disagree with me, and my ideas would go unopposed.

  2. It’s easy to choose the recipe – I would write letters on behalf of others (in my wording) and then ask them to sign. I’d choose the agendas for meetings because everyone else was too busy to respond to my emails.

We go home thinking we’ve made a lovely cake, but in reality, it’s not the cake Lisa would have made if she’d been allowed to lead. And the power imbalance means that Lisa’s mum might not call and say so, meaning that we’d never get that feedback.

I’m learning to adapt my behaviour when working within our partnership, to try to move things forward whilst ensuring that my voice isn’t the loudest one and the resulting cake isn’t only my design.

Some words of advice…

  1. Be patient… ask Lisa what kind of cake she wants to make, and really listen to her answer.

Allow enough time for local voices to be heard, even if it means something happens more slowly. Ensure that the recipe used is a local one – not one from your own recipe book!

  1. Shut up… let Lisa speak and don’t interrupt her.

Never be the first one to answer a question or give an opinion. Some gentle encouragement for others to speak up, or just going around each person individually ensures that the loudest (often western) voices don’t dominate.

  1. Lean out… let Lisa be the star of her own show. It’s her mum’s cake, after all.

Use privilege to bring in those with less of a voice. When asked to speak about a country, bring in a local rather than speaking on their behalf.

  1. Get meaningful feedback… don’t leave thinking you’ve made a lovely cake without checking with Lisa first that she agrees. Ask her, and really listen to her answer.

Ensure that the way we measure success defines success from a local perspective, and not just ours.

I am still learning, just like that slightly pushy 11-year-old. Lisa and I remain good friends, hopefully on equal terms, and she has turned out to be a far better baker than me. We, as leaders, can choose to perpetuate power imbalances or to strive to level the playing field. I believe that leadership styles matter and can make such a difference to the end result.



Lesley Crichton is a consultant in Anaesthesia and Critical Care, based in Tayside, Scotland. She is the Global Citizenship Lead Champion for NHS Tayside. She lived in Zambia for two years from 2017-2019, where she worked with her Zambian colleagues to support and develop anaesthesia training in the country.



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