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Striving towards true equity in global health: A checklist for bilateral research partnerships
review-article
Author(s):
Daniel Z. Hodson
1 ,
Yannick Mbarga Etoundi
2
,
3 ,
Sunil Parikh
1
,
4 ,
Yap Boum II
5
,
6
,
7
,
*
,
Publication date (Electronic):
18 January 2023
Journal:
PLOS Global Public Health
Publisher:
Public Library of Science
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Abstract
Interest in “global health” among schools of medicine, public health, and other health disciplines in high-income countries (HIC) continues to rise. Persistent power imbalances, racism, and maintenance of colonialism/neocolonialism plague global health efforts, including global health scholarship. Scholarly projects conducted in low- and middle-income countries (LMIC) by trainees at these schools in HIC often exacerbate these problems. Drawing on published literature and shared experiences, we review key inequalities within each phase of research, from design through implementation and analysis/dissemination, and make concrete and practical recommendations to improve equity at each stage. Key problems facing global health scholarship include HIC-centric nature of global health organizations, paucity of funding directly available for LMIC investigators and trainees, misplaced emphasis on HIC selected issues rather than local solutions to local problems, the dominance of English language in the scientific literature, and exploitation of LMIC team members. Four key principles lie at the foundation of all our recommendations: 1) seek locally derived and relevant solutions to global health issues, 2) create paired collaborations between HIC and LMIC institutions at all levels of training, 3) provide funding for both HIC and LMIC team members, 4) assign clear roles and responsibilities to value, leverage, and share the strengths of all team members. When funding for global health research is predicated upon more ethical and equitable collaborations, the nature of global health collaborations will evolve to be more ethical and equitable. Therefore, we propose the Douala Equity Checklist as a 20-item tool HIC and LMIC institutions can use throughout the conduct of global health projects to ensure more equitable collaborations.
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Most cited references76
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Emergence and clonal expansion of in vitro artemisinin-resistant Plasmodium falciparum kelch13 R561H mutant parasites in Rwanda
Aline Uwimana, Eric Legrand, Barbara H. Stokes … (2020)
Artemisinin resistance (delayed P. falciparum clearance following artemisinin-based combination therapy), is widespread across Southeast Asia but to date has not been reported in Africa 1–4 . Here we genotyped the P. falciparum K13 (Pfkelch13) propeller domain, mutations in which can mediate artemisinin resistance 5,6 , in pretreatment samples collected from recent dihydroarteminisin-piperaquine and artemether-lumefantrine efficacy trials in Rwanda 7 . While cure rates were >95% in both treatment arms, the Pfkelch13 R561H mutation was identified in 19 of 257 (7.4%) patients at Masaka. Phylogenetic analysis revealed the expansion of an indigenous R561H lineage. Gene editing confirmed that this mutation can drive artemisinin resistance in vitro. This study provides evidence for the de novo emergence of Pfkelch13-mediated artemisinin resistance in Rwanda, potentially compromising the continued success of antimalarial chemotherapy in Africa.
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Decolonising global health: if not now, when?
Ali Murad Büyüm, Cordelia Kenney, Andrea Koris … (2020)
Summary box The current global health ecosystem is ill equipped to address structural violence as a determinant of health. Histories of slavery, redlining, environmental racism and the predatory nature of capitalism underpin the design of global and public health systems, resulting in structural, racial and ethnic inequities within Black, Indigenous and People of Color (BIPOC) communities globally. While the manifestation of inequity in individual countries or regions is bound up in the local-to-global interface of historical, economical, social and political forces, COVID-19 disproportionately affects BIPOC and other marginalised communities. Aside from direct health impacts on marginalised communities, exclusionary colonialist patterns that centre Euro-Western knowledge systems have also shaped the language and response to the pandemic—which, in turn, can have adverse health outcomes. Decolonising global health advances an agenda of repoliticising and rehistoricising health through a paradigm shift, a leadership shift and a knowledge shift. While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health. Introduction The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has grinded the world economy to a halt and upended health systems across the globe, contributing to disruptions in routine health services and skyrocketing rates of death.1 Against this backdrop, the pandemic highlights with renewed clarity the way structural violence operates both within and between countries. Defined as the discriminatory social arrangement that, when encoded into laws, policies and norms, unduly privileges some social groups while harming others, this concept broadens our thinking about drivers of disease.2 While the manifestation of inequity in each country or region is bound up in the local-to-global interface of historical, economical, social and political forces, COVID-19 disproportionately affects the world’s marginalised, from Black, Indigenous and People of Color (BIPOC) communities in North America to migrant workers in Singapore.3 Health outcomes related to SARS-CoV-2 infection such as access to emergency services and prolonged intensive care, capacity to prevent infection through non-medical countermeasures like handwashing and social distancing, and economic security while in lockdown are all mediated by the confluence of global, regional and local systems of oppression. This reality shows that the current global health ecosystem is ill equipped to address structural violence as a determinant of health, and the system itself upholds the supremacy of the white saviour. As early career global health practitioners, we see this pandemic as an opportunity to critically appraise what is not working and to offer an alternative vision for the future of global health. Global health needs integrated, decolonised approaches—advanced by individuals and institutions—that address the complex interdependence between histories of imperialism with health, economic development, governance and human rights. The global movement to Decolonize Global Health, led by students and other professionals, is one step towards this vision.4–8 In this commentary, we draw on examples that show how the most vulnerable and marginalised in society are ignored and exploited by design and in context-specific ways in the pandemic response. Through these examples, we call for a threefold shift in global health research, policy and practice. Structural determinants of health for the marginalised majority The disadvantaged and marginalised make up the global majority. This ‘marginalized majority’ is strategically divided and disempowered by deep-seated racial, ethnic and financial inequities that fuel structural determinants of health. These kinds of power imbalances are by design and are by no means unique to the field of global health, yet health is often the locus of where many of these inequities intersect. Globally, histories of slavery, redlining, environmental racism and the predatory nature of capitalism underpin the design of global and public health systems, resulting in structural, racial and ethnic inequities within BIPOC communities. This pandemic widens these pre-existing inequities even further. Black and Brown people make up a significant portion of the essential workforce in many settler colonial states.9 10 Yet, they are often underpaid, underinsured and more likely to live in overcrowded, polluted and food insecure conditions that further increase their risk. Consequently, these communities have faced disproportionate rates of severe outcomes and deaths due to COVID-19.11 Without acknowledging these oppressive forces, the pandemic response will lack context-specific and targeted policies to address the structural racism that enforces these health disparities. For example, Singapore’s treatment of migrant workers illustrates how ignoring structural determinants of health has disastrous consequences for both those marginalised and the broader society. Singapore’s 1.4 million migrant workers from India, Bangladesh, China and other nearby countries encompass one-third of the country’s workforce. They leave their home countries for a better chance to sustain their families, break cycles of poverty and escape archaic forms of social hierarchies like the caste system. Despite playing a pivotal role in Singapore’s development, migrant workers live in the margins of society, often cramped in dorms with 10–20 people to a room. This marginalisation led to Singapore ignoring them in its pandemic response. Initially credited as exemplary, Singapore’s success has been reversed with a current infection rate of 1000 new cases per day, attributed to a spike in infections among migrant workers. Migrant workers are touted as ‘the invisible backbone’ of Singapore, yet SARS-CoV-2 has lifted the smokescreen to reveal how little these workers are actually valued, resulting in Singapore’s failure to protect them from the virus and to protect the entire nation from a resurgence in cases.12 The impact of SARS-CoV-2 on Indigenous peoples in the USA is another potent example of how structural violence prevents equal access to health and appropriate medical care, and leads to disproportionate suffering and premature death. The systematic destruction and dispossession of Indigenous communities through violent colonial practices in the USA has left communities like the Navajo, which has among the highest infection rates in the country,13 with poor access to healthcare and a higher prevalence of comorbidities that increase their risk of contracting and dying from COVID-19. Furthermore, contemporary policies governing ethnic and racial categories in health reporting—in which Indigenous communities are often categorised as ‘other’14—skew their official death rate from COVID-19 and result in the continued erasure of these communities. Not properly accounting racial and ethnic minorities in these totals ignores the severity of the pandemic’s impact on these communities and erases the historical injustices that put them at greater risk in the first place. Colonialist patterns shape the language and response to the pandemic Aside from direct health impacts on marginalised communities, colonialist patterns that centre Euro-Western knowledge systems have also shaped the language and response to the pandemic—which, in turn, can have adverse health outcomes. The occupiers of the highest tiers of the social hierarchy have long used scapegoating in times of crisis to divert attention from root causes of the crisis at hand. During the Black Death, Jewish communities were systematically targeted; during the AIDS pandemic, men who have sex with men and others in the lesbian, gay, bisexual, transgender and queer community were ostracised; and now, in 2020 with the outbreak of SARS-CoV-2, we see a repeat of history.15 With labelling such as the ‘Wuhan Virus’ or the ‘Chinese Virus’, Chinese and other East Asian populations worldwide are being scapegoated and facing discrimination. Another way COVID-19 has further been racialised to uphold colonialist beliefs is seen with international news headlines such as ‘Why don’t Africans have the disease?’ This attitude reveals an assumption that countries described as the ‘Global South’ could not be doing better than the so-called ‘Global North’.16 As another example, French scientists suggested that Africa be the testing grounds for SARS-CoV-2 vaccine trials, invoking imperialist and colonialist ideologies that ‘some lives were more valuable than others.’ How, in March 2020 when this statement was made, could anyone practising global health deem it appropriate to use Black and Brown communities as ‘guinea pigs’ to promote the health of white, colonialist counterparts?17 The answer lies in the persistence of racist patterns that have yet to be fully dismantled. Numerous success stories emerging from the ‘Global South’ counter this false narrative of Eurocentric superiority. Kerala, for example, a southwestern state in India, implemented highly coordinated state-wide lockdowns and test-and-trace strategies to effectively contain and control the virus.18 Among all the negative media coverage of India so far, however, this narrative of success is rarely highlighted or acknowledged. Likewise, in Africa, Senegal has become a leader in their pandemic response strategies, which include innovative technologies to reach entire populations with affordable tests for the virus. International coverage of the continent, however, instead has focused on the assumed inevitable failure of African nations to effectively respond to the pandemic, failures which are often caused by limited resources resulting from colonialism and modern-day imperialism. This representation is obviously biased, and is so because those with power to control the narrative around the pandemic continue to be disproportionately not from or based in the ‘Global South’.19 20 This imbalance, driven by what WHO Director General Tedros Adhanom Ghebreyesus termed a ‘colonial hangover’, also plays out in what gets recommended as a good pandemic response strategy.21 Global health institutions based in the ‘Global North’, often lacking representation of key communities at the decision-making table, end up perpetuating a Eurocentric worldview that does not adequately consider most of the world’s needs. The notion of simply ‘copy-pasting’ strategies like lockdowns and social distancing measures does not work in spaces like cramped migrant worker dormitories, refugee camps, urban slums or anywhere else the poorest and most marginalised are forced to reside. How can a family of 15 lock down in a slum complex that houses 700 000 others? How can you practise good hygiene such as handwashing when water itself can be a scarce commodity? When the people in power represent only those with social dominance, the health needs of the marginalised majority inevitably get overlooked. In the wake of the pandemic, these colonial trends that we see time and time again must be reversed. A decolonising agenda for health equity, beginning with COVID-19 To uproot these sources of health inequity, all practitioners and researchers should leverage the disruptions caused by this pandemic to more critically reflect on their actions. More and more voices call for recognising and redressing these imbalances in global health.22–24 From activists to professors, non-governmental organisation leaders to clinicians, a decentralised alliance is building, demanding that global health practitioners meaningfully engage with global and local structures that drive health inequities. Within that coalition, the student-led decolonising global health movement serves an important but limited function: to help create space for critical, anticolonial reflection within large, influential and privileged institutions, agencies and organisations, so far often in high-income countries (HIC), that are responsible for driving global health discourse, ‘knowledge’ and funding flows.25 This movement advances an agenda of repoliticising and rehistoricising health. We believe that the movement broadly calls for the following: Paradigm shift: Repoliticise global health by grounding it in a health justice framework that acknowledges how colonialism, racism, sexism, capitalism and other harmful ‘-isms’ pose the largest threat to health equity. Without confronting the impact these interlocking systems have on health, global health activity, despite best intentions, remains complicit in the ill health of the world’s marginalised. A paradigm shift involves individuals and institutions acknowledging that disease cannot be extracted or isolated from broader systems of coloniality.26 27 Organisations and donors should adapt their missions, programming and structures to account for this reality. Fundamentally, this shift means changing who sits at the table and rebuilding parts of the table itself. Leadership shift: Leadership at global agenda-setting institutions does not reflect the diversity of people these institutions are intended to serve. First, the ‘Global North’ needs to ‘lean out’ on an individual, national and institutional level to stop reproducing racist and colonialist ideologies.28 Unsurprisingly, experiences from the ‘Global South’ show that it is a hotbed of innovation, and leaders in the ‘Global South’ must be recognised and elevated for their contributions. Second, gender disparities in global health leadership need to be addressed and remedied. In many global health institutions, women, especially women of colour, are under-represented and their voices are excluded in policy and programmatic formulation.29 30 A leadership shift would include more equitable representation in academic journals, leadership roles and faculty make-up, reflected, for example, in equitable first authorship positions for collaborators from the ‘Global South’ and women.31 32 Knowledge shift: To avoid perpetuating the kind of racist and colonialist pandemic response we see with COVID-19, it is vital to ensure knowledge flow is not unidirectional, but instead reciprocal with contributions from the ‘Global South’ driving discussions and practice, both locally and globally; a twofold knowledge shift.33 The first includes teaching students about inequitable global disease burdens while creating an enabling environment for critical inquiry into the racist and colonial histories that gave rise to these disease burdens. The second is to bridge geopolitical imbalances in global health education. For example, global health training programmes and knowledge resources are mostly offered in the English language, in HICs and at great cost, thus limiting access for people of other languages, and from less privileged backgrounds. To promote anticolonial thought by encouraging training and knowledge sharing without these obstacles, we need to change existing platforms and create new learning platforms for global health. Conclusion The pandemic response reveals with stark and sobering clarity that current paradigms of global health equity are insufficient in counteracting structural oppression. By focusing on individual risk factors and siloing funding based on disease, global health agendas—including pandemic responses—ignore how health risks are shaped structurally by laws, policies and norms, ranging from regional trade agreements and immigration policies to racial discrimination and gender-based violence. Structural inequities reproduced within the global health system itself—such as over-representation of affluent white men from HICs in global health leadership positions34—highlight the lack of critical engagement with the geopolitical determinants of health disparities. While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health. A student-led decolonising movement is one step. Now, the movement must expand in numbers and scope to create a more just and equitable future.
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The foreign gaze: authorship in academic global health
Seye Abimbola (2019)
I was really interested in black readership. For me the parallel is black music, which is as splendid and complicated and wonderful as it is because its audience was within; its primary audience. The fact that it has become universal, worldwide, anyone, everyone can play it, and it has evolved, was because it wasn’t tampered with, and editorialised, within the community. So, I wanted the literature that I wrote to be that way. I could just go straight to where the soil was, where the fertility was in this landscape. And also, I wanted to feel free not to have the white gaze in this place that was so precious to me… —Toni Morrison (1931–2019)1 And I have spent my entire writing life trying to make sure that the white gaze was not the dominant one in any of my books. The people who helped me most arrive at that kind of language were African writers… Those writers who could assume the centrality of their race because they were African. And they didn’t explain anything to white people… “Things Fall Apart” [by Chinua Achebe] was more important to me than anything only because there was a language, there was a posture, there were the parameters. I could step in now, and I didn’t have to be consumed by or concerned by the white gaze. —Toni Morrison (1931–2019)2 Introduction There is a problem of gaze at the heart of academic global health. It is difficult to name. Replace the word ‘white’ in the Toni Morrison quotes above with the word ‘foreign’, and you may see what I mean. Better still, read on. Because without naming this problem, we cannot have holistic discussions on imbalances in the authorship of academic global health publications. Recent bibliometric analyses3–6 (some of which have been published in BMJ Global Health 7–9) confirm patterns that are largely explained by entrenched power asymmetries in global health partnerships—between researchers in high-income countries (often the source of funds and agenda) and those in middle-income and especially low-income countries (where the research is often conducted). But we cannot talk about authorship without grappling with who we are as authors, who we imagine we write for (ie, gaze), and the position or standpoint from which we write (ie, pose). It is tempting to proffer specific or direct solutions to these imbalances in authorship (some have appeared in BMJ Global Health, and we welcome more) with initiatives that include having journals, funders, universities and their governing bodies mandate the inclusion of local authors, change academic promotion criteria so that foreign experts can more readily give up choice authorship positions, provide resources to low-income and middle-income country academics to engage more equitably in partnerships, change the criteria for authorship so that more roles are recognised, and increase the diversity of journal editorial boards.8–15 In my view, these measures are, in many cases, necessary. But I often wonder if (without addressing the problem of gaze) these solutions can result in moral licensing—that is, can the self-congratulation that will very likely accompany having these measures in place make us excuse ourselves from addressing more fundamental issues of authorship? This editorial is based on my experiences as a journal editor, and also an academic who has been a local researcher and a foreign researcher.16 It is also based on a constructed ‘ideal’17 of how things might have been without global health research partnerships, and when (circa late 19th to mid-20th century) many of the countries that are now high-income countries experienced significant improvements in health outcomes and equity,18 that is, an ‘ideal’ of local people writing about local issues for a local audience. I deploy this ‘ideal’ not as a prescription, but only as a heuristic device. And by applying this sense of ‘ideal’, I wrestle, rhetorically, with three questions that come to mind and give me pause, whenever I consider solutions to imbalances in authorship, especially those solutions that are based on mandates and strictures. The questions are: (1) What if the foreign gaze is necessary? (2) What if the foreign gaze is inconsequential? (3) What if the foreign gaze is corrupting? What if the foreign gaze is necessary? This question stems from the notion that the requirement for balance in authorship in global health research partnerships is not self-evident. The research questions addressed in such partnerships may be best posed by foreign experts, and their findings best written for a foreign gaze. In such a situation, does it matter if the authorship is skewed towards or entirely foreign experts? While the local gaze is important, we cannot presume that the ‘ideal’ of local people writing about local issues for a local audience will always hold. And because such a situation in which the foreign gaze is necessary should be an exception rather than the rule, perhaps such papers should be so labelled by the lead author ‘written with a foreign pose for a foreign gaze’, with the justification for such an exceptional choice of pose and gaze clearly and visibly articulated in the paper. Perhaps in a box, just below the list of authors, or as a footnote, next to conflict of interests. Let us explore one such potential scenario. Take for example, a hypothetical paper written by a foreign expert, about burial practices in West Africa. This academic was deployed as part of a team of anthropologists to support efforts to address an Ebola outbreak. Through their anthropological work, this academic helped the ‘foreign-led’ team in West Africa make sense of local practices, thus contributing towards making strategies for adapting burial practices in the wake of the Ebola outbreak more effective—because the burial of loved ones who died from the infection is often a channel of contracting the Ebola virus. The audience for whom the paper was written would likely be other anthropologists who perform similar service in other countries working as foreigners—a role that may not exist if all such response teams were led by local experts—that is, if every country had the capacity (especially, the funds) to respond to their own outbreaks. In an ‘ideal’ scenario—that is, the anthropologist is a local expert who speaks the same language as their fellow locals, with the same burial practices, and works within a team of other local experts—the paper is different: ‘written with a local pose for a local gaze’. Here is a worthwhile thought experiment: how will the content, emphasis, style and framing of a paper ‘with a local pose for a local gaze’ differ from one ‘with a foreign pose for a foreign gaze’? We can extend that question to other deviations from the ‘ideal’ pose and gaze (see figure 1)—that is, ‘written with a local pose for a foreign gaze’ and ‘written with a foreign pose for a local gaze’. Typically, these choices are neither consciously made nor explicitly declared. But they should. Such a declaration could function as a short form of authorial reflexivity, and help academics, foreign and local, to be more deliberate in their choices and attitudes, and help readers to better place the purpose of a paper. Figure 1 The authorial reflexivity matrix, with combinations of local and foreign pose and gaze. This authorial reflexivity can give permission to the foreign expert, who, recognising the limits of what they can see or understand, chooses to write for other foreign experts, primarily; and can expose the hubris of a foreign expert who does otherwise. But note that the local versus foreign pose can shift depending on the person and the topic; an anthropologist from the same West African country, but of a different ethnicity to the location of the outbreak, may be a foreigner in relation to burial practices—foreignness could be defined by ethnicity, race, caste, geography, socioeconomic status and the issue in question. The declared authorial reflexivity can also help readers or bibliographers understand the reasoning behind the pose and gaze—for example, there is no local (with capacity) available, the pose and/or gaze does not matter, the message is best suited for a foreign audience, or the lead author knows too little to have anything of value to say to local experts. What if the foreign gaze is inconsequential? The alternative, longer, form of this question is: ‘what if it is indeed the local (rather than the foreign) gaze that is consequential?’ (see figure 1). To explore its implications, let us return to our foreign anthropologist in West Africa, but one who chooses to write primarily for local experts—that is, ‘with a foreign pose for a local gaze’, in an effort to approximate the ideal—that is, ‘with a local pose for a local gaze’. Such a paper would be published where our ‘ideal’ paper is published: in local journals, many of which may not be indexed in global databases or published in English,19 but contain publications addressing research questions and policy issues that would exist, irrespective of the presence and influence of foreign experts, foreign funds, foreign donors, foreign helpers or foreign collaborators. Just consider the sheer volume of such publications. Indeed, most academic global health papers are local,20 many of them in outlets that are deemed ‘predatory’.21 22 How consequential is this minority of academic global health publications written for the foreign gaze? It is almost certain that local output is much more consequential, if only because sustainable progress in global health is homegrown, with local processes being responsible for much historical improvements in global health outcomes and equity23–27—and, for example, there is as yet no association between the density of papers in global databases on universal health coverage from a country and its attainment by the country.28 What gets written for the foreign gaze reflects the appetite of the foreign gaze,29–35 which is more attuned to the ‘surgical’ than to the ‘organic’.36 It is much easier to see ‘surgical’ change (as the agents of change are tangible, short-term, often external) than it is to see ‘organic’ change (as the agents of change are diffuse, long-term, typically internal). We must get better at recognising and explaining long-term change.37 Papers written for the foreign gaze represent only a slice of reality; only a subset of publications originating from a country that may advance the cause of global health in that country. In some cases, it is an important slice, but a slice, nonetheless. Too much focus on this subset unduly emphasises discrete, short-term and episodic efforts, often initiated or led from outside. But emerging evidence from several low-income and middle-income countries suggests that long-term change is brought about by local process, policies and dynamics—for example, the role of women’s empowerment in explaining long-term change in child health outcomes.38–41 It is unfair, and even misleading and colonial to pay undue attention to the foreign gaze. And if the academic literature to which we give priority does not reflect that local experts are at the forefront of addressing local problems, then there is something deeply wrong with that literature, because it does not reflect reality. We must rethink our attitude to ‘local’ journals and take some responsibility for why many local experts publish in ‘predatory’ journals.21 22 If we are keen about the local gaze, we will seek to publish our work in the same journals where local experts exchange ideas; local journals and outlets will have their proper place in our imagination, and perhaps some of the shady entrepreneurs behind predatory journals may have founded legitimate peer-reviewed journals instead.21 22 Why, for example, should it be normal that a trial of strategies to reduce maternal mortality in rural India gets published in a journal based in Boston or London instead of Bangalore? Perhaps, we should extend our authorial reflexivity, so that it includes the justification for the choice of a foreign journal—for example, because it is a multicountry study, the findings are irrelevant to a local audience, funder’s expectation, the journal’s impact factor, or for promotion, grants and prestige. What if the foreign gaze is corrupting? This question has particular resonance for me and many people I know. To explain what I mean, let us return again to our anthropologist; this time, a local anthropologist, who, although a local expert, chooses to write primarily for a foreign audience. As pose is often determined by the gaze of the spectator, the foreign gaze can alter the local expert’s pose. The choice that a local expert makes about the audience that they want to inform or impress can corrupt their message (see figure 1). The local expert makes a trade-off—between on the one hand, the need to tell it like it is, and on the other hand, an effort to globalise the use of language, to make their message intelligible to an audience with little background knowledge, to sanitise the reality that they wish to convey, to hide the dirty linen. When the foreign gaze wins over, as it often does, complexity, nuance and meaning (eg, about local burial practices) can be lost, especially for the local audience. The foreign gaze can make a local expert write like an expatriate—as often detectable in the language of local experts who work closely with foreign experts, or of postcolonial literary fiction written for the foreign gaze.42 Further, this phenomenon can also corrupt the local expert’s own sense of reality—in the process of massaging, simplifying and altering reality, the local expert stands the chance of also losing their own sense of reality; the sense of complexity and of multidimensional reality that is often necessary to address delivery problems in global health.43 An additional corrupting influence of preoccupation with the foreign gaze is that it can distract (especially) local experts from engaging in the often consequential and often non-academic conversations in their own setting, some of which are not had in the English language, which should be at the centre of academic global health discourse, but unfortunately are often not taken as seriously.44 The most important conversations about health policy, systems and delivery in many low-income or middle-income countries do not make their way into peer-reviewed journals (whether local or global), and, perhaps, neither should they. I glean them on email listservs, local newspapers, local blogs, local radio, WhatsApp groups and even on Twitter. It would be both colonial and anachronistic to expect or require that such conversations be had in global journals, which many of the participants do not read and should not be expected to read.44 But it should also be unacceptable, that, like ships in the night, local and global conversations often pass each other by. The challenge is to create channels through which the content of some of these conversations can make their way into the academic global health literature, channels that can help to recognise, amplify and draw insight from local conversations without, extractively, asking for them to move to foreign platforms. To make global health truly global is to make global health truly local. Perhaps what our local anthropologist who is keen to write for a foreign gaze must do is write two versions of the same paper—one written from a foreign pose for a foreign gaze, and another written from a local pose for a local gaze, for example, a local newspaper or blog, perhaps in a local language.44 And in the version written from foreign pose for a foreign gaze, the local expert should explain the reasoning behind that choice and the impact of the foreign gaze on their pose, on their prose, their language, their style, on what they chose to include and exclude in their paper, on the aspects of reality that they left out, and where the local audience might find the version written for them. The local expert may do this in a statement, as part of the declaration on authorial reflexivity, inside the box, just below the list of authors, or as an extension of the footnote, next to conflict of interests. Conclusion In many ways, the growing concerns about imbalances in authorship are a tangible proxy for concerns about power asymmetries in the production (and benefits) of knowledge in global health. In fact, authorship per se is not the fundamental issue; undoing what those imbalances represent—a continuity of the colonial project in global health—is often the issue. And the ongoing discussions on authorship in academic global health is an opportunity to have the necessary conversations that go beyond mere representation on lists of authors—through open self-reflections or reflexivity (about which much can be learnt from ongoing efforts to decolonise anthropology45–47), aided by the ‘authorial reflexivity matrix’ (see figure 1), on the situations that lead us to make less than ‘ideal’ choices about authorship, why those choices are sometimes necessary, how to make our work in those less than ‘ideal’ situations more consequential, and our choices less corrupting. For me, the implications of the three questions explored in this editorial are inescapable. The foreign gaze is inevitable. In a globalising world, our destinies are interlinked, and the origins of and solutions to delivery problems in global health can be local or foreign. But in a world of power and information asymmetries, we see differently and understand differently; and much too often, the power to act is not directly proportional to the information on which to act.48 There will always be gaps between what local experts see and what foreign experts can possibly see.16 But more and open conversations on the place of the foreign gaze, of local knowledge and of organic (rather than surgical) change in global health are—and can help us identify other—strategies to fundamentally undo colonial practices and attitudes. The proposed reflexivity statements can be a starting point—but only in the hope that, in this case, sunlight may, in fact, be the best disinfectant.
Author and article information
Contributors
Abdisalan Mohamed Noor: Role: Editor
Journal
Journal ID (nlm-ta): PLOS Glob Public Health
Journal ID (iso-abbrev): PLOS Glob Public Health
Journal ID (publisher-id): plos
Title:
PLOS Global Public Health
Publisher:
Public Library of Science
(San Francisco, CA USA
)
ISSN
(Electronic):
2767-3375
Publication date
(Electronic):
18
January
2023
Publication date Collection: 2023
Volume: 3
Issue: 1
Electronic Location Identifier: e0001418
Affiliations
Author notes
Author information
Daniel Z. Hodson
https://orcid.org/0000-0003-4801-0147
Sunil Parikh
https://orcid.org/0000-0001-9411-5180
Yap Boum II
https://orcid.org/0000-0002-6823-8539
Article
Publisher ID: PGPH-D-22-01196DOI: 10.1371/journal.pgph.0001418
PMC ID: 10021183
PubMed ID: 36963065
SO-VID: e01e4e78-1e76-4a78-8e4d-c2507baf2323
Copyright © © 2023 Hodson et al
License:
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
History
Page count
Figures: 1,
Tables: 2,
Pages: 15
Funding
The authors received no specific funding for this work.
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