Undisciplinary
Undisciplinary
Decolonizing Health: Why "Global" Health Is a Problematic Concept with Seye Abimbola
A/Prof Seye Abimbola explores how global health as a concept reinforces colonial power structures and argues for decentering Western institutions in health governance. His critique reveals how aid flows primarily benefit donor countries while creating dependencies that hinder meaningful health system development in recipient nations.
• The term "global health" itself is problematic, describing an industry with colonial roots rather than a truly global approach to health
• Much international aid functions as "tied aid," where donor countries require recipients to purchase overpriced products from them, limiting actual benefits
• 84% of major global health organizations are headquartered in wealthy nations, perpetuating knowledge hierarchies and power imbalances
• Historical colonial medical interventions like brutal sleeping sickness campaigns continue to impact health outcomes and trust in healthcare today
• Prestigious biomedical journals marginalize qualitative research, reinforcing knowledge hierarchies that privilege Global North perspectives
• True decolonization requires addressing not just authorship imbalances but ensuring research questions and methodologies serve local needs
• The withdrawal of USAID funding presents both challenges and opportunities for African nations to reimagine health systems on their own terms
Check out Dr. Abimbola's book "The Foreign Gaze: Essays on Global Health" available open access, which further explores how knowledge practices in global health often serve foreign interests rather than addressing local needs.
We also discussed Kyobutungi C, Okereke E, Abimbola S. After USAID: what now for aid and Africa? BMJ 2025; 388 :r479 doi:10.1136/bmj.r479
Undisciplinary - a podcast that talks across the boundaries of history, ethics, and the politics of health.
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Undisciplinary is recorded on the unceded lands of the Wadawurrung peoples of the Kulin Nation in Geelong and the Gadigal peoples of the Eora Nation in Sydney. We pay our respects to Elders, past and present. The world's first heart transplant has been performed. Medical history has been made in South Africa.
Speaker 3:Reports of systemic racism in the healthcare system and.
Speaker 2:COVID-19 has made the issue even more urgent.
Speaker 1:Welcome to Undisciplinary, a podcast where we're talking across the boundaries of history, ethics and the politics of health, co-hosted by Chris Mays and Jane Williams. Jane Williams, okay. So welcome, jane, to another episode of Undisciplinary, and this week I think we can just get straight into it. We are having a return guest which we're excited about, and we're going to be talking about, I suspect, many things to do with global health and the continued rolling fallout of the Trump presidency and its effects around the world. So, rather than hearing my ramblings about that, who have we got to talk about this, jane Morning, chris who have we got to talk about this?
Speaker 3:Jay Morning, chris. Today I am super happy to welcome back Shea Abimbola, who is a health systems researcher from Nigeria and an associate professor at the School of Public Health at the University of Sydney in Australia. My boss's boss, that's how senior you are. Shea teaches and studies knowledge practices in global health, health system governance and the adoption and scale-up of innovations. And, as Chris mentioned, we had Shaya on the podcast before two years ago somehow I don't know what happens to time, all of that and I'd really encourage people to listen to that because we've got a lot of Shaya's sort of background and inspiration for what makes him the scholar he is today, and we're not going to repeat that because we've done it before. But in the couple of years since we talked to Shaya last time, he has published some really terrific papers and a book called the Foreign Gaze, and we will link to those in the notes, won't we, chris?
Speaker 1:We will yes.
Speaker 3:Thank you. So I wanted to kick off with a question, if that's all right. That it's always just been a bit weird for me, and I'm hoping that there will be a really easy answer what's global health?
Speaker 2:I suspect it's weirder for me than it is for you.
Speaker 2:But thank you very much, Chris and Angel, for having me back again. It's nice to be back. I don't know what it means really. I don't know what it means really, and there are expressions like that in my work that I either don't know what it means or I wish it didn't mean what people thought it meant. That would include words like resilience, say, or health security. They're sort of concepts that I just wish either didn't exist or meant something completely different, and global health is like that.
Speaker 2:I feel in many ways that part of my responsibilities is to define global health out of existence in other words, to try very hard to make the word global so saliently redundant for people that it just becomes something people don't feel the need to say in relation to health, because, of course, health is a global phenomenon, it doesn't need to be said, and that we use that expression today means there's an industry. It refers more, to my mind, to an industry or a set of institutions that perform a function that is described as global health. Now that function sometimes is about the global governance of health. Again, to my mind, the global governance of health makes sense, but we didn't say the global governance of global health. You see what I mean. So it's the global governance of health.
Speaker 2:Who, et cetera, who do that? Who, et cetera, who do that? It's also often used to refer to research done internationally, and to my mind that's just international research for health. It is also often used to describe work practice done internationally, which one may say someone who goes from Sydney to do health work in PNG is doing global health, and I would ask myself if someone from PNG is doing exactly the same thing, would we say they were doing global health?
Speaker 3:I mean so it gets in many ways almost all the usages of it.
Speaker 2:there's something about it that's just not necessary in my mind, so I'd rather that we hopefully get to a point where we no longer need to say that.
Speaker 3:Yeah, and I guess there's all sorts of implicit like if someone from Sydney is going to London to do something about health, we're not talking about global health, right? So, like, just all of the unspoken work that global is doing. There is why I've always just been like, you know, maybe it's just about saying the quiet bits out loud and not yeah.
Speaker 2:I love your response.
Speaker 3:Let's make it as obsolete as it actually is, you know.
Speaker 1:Just before we do that. Yes, no, I'm all for the project of making it obsolete, just maybe for some people who aren't, as I guess, aware of some of these problematic uses and the way that it has been used, perhaps you know we can think about individual health. I'm just curious about the analogy or the scaling up and then where the step goes wrong. So you know we can think about individual health. And maybe you know biomarkers, blood pressure, you know those sorts of things that we can measure for an individual person and have, you know, measure, you know whether it's epidemiology and incidences of diseases and infrastructures and those sorts of things that can support and address the health of a population and a collective. You know, however, defined, where those borders end.
Speaker 1:I guess is a question for public health, but that conceptually seems to make sense. And then that jump to global health is a different something. There's a sort of qualitatively distinct. So, to use your example, someone in Sydney could go to Port Moresby and be working on public health you know whether it's vaccine rollouts or those sorts of things and someone from Port Moresby could come to Sydney and be working on public health, but when they go to be doing global health, there's something different going on. There's not an analogy, there's not that global equivalent to the public.
Speaker 2:Yes, and what you described, I think, points to the history of the field that is today called global health. It comes from an almost parallel line to public health. Historically, right, it's often been considered to be separate, that it's begun in many ways as part of the colonial mission of Western countries in other parts of the world and as an aid to furthering that mission, such that the practices of it, necessarily, if you really examine what is being done, a huge chunk of it is public health, but the other chunk of it is serves a function of making it easier for colonization to work. So there are two things side by side and there have always been in many ways, those two things side by side.
Speaker 2:On the one hand, you are doing health necessary, good, important work. On the other hand, you are doing work that is evil, and those two things have sat uncomfortably next to each other in the field ever since up to today, that when you look at the infrastructure of global health as it is today, you still see those two things. And there is that flow that it comes from a rich country to a not rich country, from the global north to the global south, and that's why when someone comes from Port Moseley to Sydney. It's's not global health, because of course that doesn't align with it, with the, with the direction of flow. But if someone were to go from sydney to port musby, then it is. It aligns with that flow, so it carries that level, so it's. I think that flow is something historically, um, determined, that's it.
Speaker 1:Yeah, and I think we'll come back to some of these flows, particularly when it comes to money as well, soon. I guess I wanted to ask, or sort of reframe maybe, some of my introductory remarks where I talked about Trump and his presidency, and it seems so you've written an article, or co-authored, after USAID, what Now for Aid and Africa? And I guess you know Trump is part of that narrative. But it seems to me that part of your editorial is a decentering of, or the opportunity of de-centering Trump, and then Trump as symbol for US and global north hegemony in aid. I wonder, yeah, firstly, if you could just talk a little bit about that editorial and about you know what now for aid and Africa.
Speaker 2:The actions of Trump in the last few months in significantly scaling back the US government's aid program, including USAID and its policies in relation to the WHO. There are actions that strangely really strangely may have been taken by a president that wasn't Trump. In other words, it didn't strike me as a, you know, peculiarly Trump action. There have been discussions within the field of global health and international development about the need to do aid and global health very differently. There have been these discussions for at least two decades. Unfortunately, these discussions have also been really marginal in the field that it hasn't had the chance to percolate into the halls of power, especially among those who hold power in the field of international development and global development, and I mean field not just in terms of research but also, more importantly, practice. So the arguments that Trump and Marco Rubio, his Secretary of State, were making about just how problematic USAID and the aid program and WHO was, they are arguments that people on the left have made for about 20 years, so it was not new, and what was interesting was that they were making those arguments. And what struck me is, you know, this line about cowards dying many times before their death, and this says that we were saying these things, but many of us in the field didn't want to go where those arguments led because we were afraid the money will go away and we didn't take the actions that we ought to have taken a long time ago. And this is, you know, everybody, not just you know, not just the US government, it's also African government. It's also global health researchers. It's also African government. It's also global health researchers. It's also USAID staff. It's many, many people who were far more taken by the work itself and the fear of losing money and keeping doing things the way they've always done it than actually standing back to examine and really reimagine what it was that we were doing. So, in a sense, all of this should have happened, and happened by us in a way that we could control and manage and be constructive about. And it's come by a vandal, and a vulgar one at that, who's just dismantled everything overnight.
Speaker 2:If I were to be the person who was in the position to redesign all of this, an argument that I will be taking seriously and that I've made many times before is just to be very honest about the purpose that aid serves.
Speaker 2:Be very honest that, for the most part, there's a good example of this that if you, if the US government, gives an African country money to buy a diagnostic for X disease, the African government could buy the same thing for $1 from China, but it costs $10 from the US and you have to buy it from the US. So if you get $10 million, for example, only $1 million in that analogy actually comes to the country. In other words, if the US government removes $10 million, what the African government needs to replace is not $10 million but $1 million. Now, that's just an example of that. And again, if we were examining closely how this deal worked, we would have, I suspect, been able to work ourselves to a place where we say, okay, what is the real, what really contributes to health on the continent, and to say the same thing for a lot of research in this field. That, again, if you're looking at sort of 10, I would hazard a guess and say maybe two out of the 10 actually matter.
Speaker 2:And again, for me it's the inability to be disciplined and not be so absorbed in our own goodness, because some of the arguments that people would make when you say, well, this thing needs to change, is that but we are saving lives. What are you doing? You are writing and talking, so you keep quiet, because, of course, how do you come back at that? Someone says they are saving lives. What do you do? How is it going to stop? So there is this sense that we have not been honest with what we're doing enough to allow ourselves to redesign, reimagine and reform, in fact, transform what it was that we've waited for a band out to be a person.
Speaker 3:I think there's this idea when people, particularly with USAID and particularly with the American population and it's what you've just said, shaya the idea that it's all just giving right rather than part of a massive financial machine so much of. I don't know if Tide Aid is a thing that is familiar to business, but the idea that a lot of what's given in an aid context is really just selling the donor country's goods and services. So it's part of a big economic machine.
Speaker 2:Yeah, and it's not always obvious to people in it.
Speaker 3:No, for sure, Exactly.
Speaker 2:And it's not always obvious as well to the recipients of it, and part of the argument we were trying to make in this editorial was just to try and make that a bit more obvious, because we can't respond to this without understanding what it is, because we can't respond to this without understanding what it is and part of, for me, the bigger argument is that, rather than beg for more aid, we should be strategizing to have the upper hand in trade negotiations, in discussions and debates about reparations and in taking control of how we do health and development we meaning Africans now, but also other parts of the global south. So for me, it's a. People have often heard the description of this moment as an opportunity in terms of being cavalier. People are going to die and you're seeing this opportunity, and there's a part of that that I understand and it's true. And there's a part of that that I understand and it's true. But at the same time, I think people who go there very readily ignore or are unable to have to say we've taken this money away, begging you from all indications, we're not bringing it back and we're going to have to do something, and it's not on the people who are going to have to do something, that people are dying because the money was taken away. It was taken away. So there is that sense, for me at least, that we to get away. So there is that sense, for me at least, that we have to see this as an opportunity because we have no other option. The lie that it's an opportunity is that there's no way else we go and to then take this almost as a trigger to do things very differently.
Speaker 2:In my health systems work, I'm often studying how learning takes place within systems and there's this framing from organizational learning literature about single loop and double loop learning. And the idea of single loop learning is you try to do something, you fail and you look for another way to do that same thing and sort of keep going. And double loop learning is when you try to do something and you fail and then you stand back and you re-examine the rationale and your mental frames for that. And I feel that on the one hand, there are many people who want us to do, who want this to be an episode of single-node learning. Let's keep going, let's keep asking for it. But for me and many of my colleagues and friends, we want this to be an opportunity for double-node learning, to stand back and say what is this and can we reorganise this thing?
Speaker 3:So can I loop back? You mentioned reparations before. I would love to hear more about that, and I will admit that the only context that I've really read about the idea of reparations is in the context of the US. Is that something that you can talk more about in the context of, I guess, colonised Africa more broadly?
Speaker 2:Yes, and it's always been. If you talk to leaders of Caribbean countries, they are far more switched on about reparations than leaders of African countries countries. They are far more switched on about reparations than leaders of African countries. I can't hazard many guesses as to why, but I find that particularly interesting, and I suspect that they are more switched on about reparation because it's much clearer to them what the tally is.
Speaker 2:One of my benefits of living in Australia is also observing. Indigenous Australians relate to Australia in that they also understand what Italy is, and I think there's something about proximity that makes you see what Italy is, what has been taken, what keeps being taken and what I want in return. So the Caribbean people see that. Indigenous Australians see that very clearly, africans don't, and I think in L. So the Caribbean people see that. The North Australians see that very clearly, africans don't.
Speaker 2:And I think in life, because we get to leave a reality in which we think that all that is wrong with our continent started yesterday. And there's this example that I often think about, and part of the problem is that a lot of things are not documented or discussed openly A lot of the costs of colonization. When you describe them, they don't seem correct because they are so that's the word I'm looking for so strange, so bizarre, like it doesn't feel real. But there's this example that I often point out and I hope you link to this paper. It's strangely in an economics journal, it's one of the strange things that happened in the world. But I think between the 1920s and 50s there were these big colonial campaigns against sleeping sickness in five countries in Central Africa and it was so brutal and they were using drugs that were not, that would not be used in Europe because it was known to be brutal, it would kill maybe up to a third of people who used it, maybe more blind, and people were forced to take it right Beaten, to take it for about 30 years. And it was well documented by the French. So the French thing, it's very well documented.
Speaker 2:The details of the numbers and locations are in archives in France and there's a group of researchers who went and collected those details and then mapped that onto the current map of health outcomes in those five countries today. And there is a shocking congruence in the places where this campaign was most intense to the places where maternal mortality, child mortality, refusal of vaccination especially, refusal of vaccination especially, etc. Are highest today and nothing else maps our capital of education, every other public policy, everything else, there's no effect. But on health, including domestic health policy and interventions, there's a huge effect. And if you go to those places today, I doubt that people will know why. I doubt that people there know why. I doubt that people there who live there now, if you ask them, but why do you not like medical intervention, why do you not like needles, why do you not like vaccines? They won't be able to tell you why. But those things persist in some of the suns in those places, as this paper described, et cetera.
Speaker 2:So my point is that a lot of what was bad continue to live now, but we don't even know. We are not even able to articulate it. That's part of what I was saying that for indigenous people in Australia, for example, for Caribbean people, it's more legible. For Africans it's less so. Now, what is far more legible for Africans is the extraction of resources, is the way trade works DRC especially, for example, but other parts of the continent but that what should be really super rich countries are the poorest because of extraction. It's also obvious in really really messed up trade deals over decades that you can tell that this is not a trade between equals.
Speaker 2:Someone is messing someone else up, so in other words, there's a way to do the tally. Some people who study taxation have been doing these tallies over the last 10 or so years, so there are better numbers now than ever before. For me, these are the arguments that I want the average African leader to take into a negotiation.
Speaker 1:It's. Yesterday I was teaching decolonial justice in a unit that I teach and one of the things we were talking about was, through the coronation of King Charles III. It brought attention to, you know, all the symbolism and the pageantry and the jewels and all of this and that it provided a good opportunity because there were a few sort of TikToks and different things where people were talking about where all of these jewels came from. And, you know, it pairs well with Frantz Fanon's writing about the wealth and decadence of Europe coming from the extraction of Africa. And yeah, when you have the star of Africa as the largest diamond in the possession of the king of England, you know it's not the star of, I don't know, essex or you know it didn't come from Essex or somewhere like that. It, you know, came from Africa. Like that, it, uh, you know, came uh from africa, um, and yeah, I think that idea of reparations um is, uh, you know, clearly an important part of the decolonizing um process in australia, africa, um, uh, and the us and elsewhere, um.
Speaker 1:Something else that occurred to me just, I guess, having just been teaching some aspects of this, we played a clip from Gary Foley, the Indigenous activist and scholar here in Australia and he just going back to some of your very early comments about Rubio and Trump talking about USAID and you were saying how those arguments had been made by other people, like 20 years before. And in this clip Gary Foley was talking about the sort of quote unquote Aboriginal industry that Pauline Hanson and other right wing people were talking about all this money going towards you know, the Aboriginal industry. And Gary Foley was saying I made that argument 20 years before. All of these right-wing people were making it because, yeah, there is all of this government money going towards these services but it's not going into. I guess the difference between the right-wing critique and the left-wing critique is the right-wing critique think that Aboriginal people are getting all of this money funnelled straight into their bank accounts and where it's really getting funnelled into all of this bureaucracy and services and other forms that to your article it seemed that there was a similarity in the way that I think I'm just going to get the figure up where you had. I think it was like 84%.
Speaker 1:84% of the largest global health organisation have headquarters in the global north and so I guess, coming back to that sort of idea of global health, meaning people going to places like png or africa or where have you, but their headquarters are all in the global north and I assume that a lot of the you know again not to I mean, I don't know these people, but I assume many of them are your colleagues or people who you, at least you know that they are, and this maybe comes in with some of your colleagues or people who you, at least you know that they are, and this maybe comes in with some of your writings in the book.
Speaker 1:You know they're all well-meaning, well-intended folks, but it's their salaries and that infrastructure as well where a lot of the money is being funneled into. So the withdrawal of that, yes, obviously, is not great for their own career situations, but in terms of global health, and if it's intention or the thought is that all of this money is going towards the health needs of people in low-income nations, then yeah, your work highlights or your argument highlights that. Then yeah, your work highlights or your argument highlights that. Yeah, I don't have anything else to say in terms of a question. It was more just. It struck me as a parallel, I guess, with just what I was talking about and thinking about yesterday with Gary Foley and the Indigenous context as well, where a lot of that money isn't actually going to, where I guess the right-wing people fear that it's going to and the left-wing people really wish that it was going to.
Speaker 2:Yes, I think there's a part of that. I mean, there is the political part of that, which is that governments of global north countries, in the context of global health, would rather that the money was spent domestically as much as possible. But when you talk to people who work in the industry and this is always something I find really strange, and you were talking about people who I must know and who are well-intended that one of the difficult things about us human beings is that we have to, we retrospectively justify the things that we do. So when you ask them, but why is it this way, even the best among global health practitioners will say but it's better if the money stayed in the global north, because there's no capacity in the global south to actually handle this. Or if you send the money there, it will be stolen. There's corruption, you see. Or that expertise. The money has to go to where the expertise is, and we have the expertise.
Speaker 2:I mean, there are all kinds of reasons that people give for this, but then you have to ask them okay, so after 20 years, let's assume you're right. After 20, 30 years, 40, 50 years, it ought not to still be right, even if you were right and you were not. But if you were, it ought not to be right decades after. So there are all these reasoning that people use to justify how things exist, and I understand that it must be because they have to be able to live with themselves, because it's hard to look at this thing for what it is and function within it with peace.
Speaker 1:Look at this thing for what it is and function within it with peace. And I mean the other thing in relation to these flows as well, of whether it's flows of knowledge or flows of capital and money. The other thing that strikes me is the and this comes back to the idea of the reparations that I think Slavoj Žižek said in relation to Bill Gates that you know, he's really just giving back some of the money with one hand that he'd already taken with the other hand, and so I think the reparations, as you have said, you know rightly need to be understood in the context of these unjust global economic orders. Jane, did you have something further you wanted to ask about?
Speaker 3:I was going to move on to a different set of questions, if that was all right, because I was really struck. I was reading another paper. Oh, I'm going to interrupt myself to suggest to the listeners that they look at the USAID website. Now, it is nuts. I had a quite good time on my phone in bed last night trying to figure out what the hell was going on. So I will just say that if you need five minutes of um, of just being having your mind blown but moving along, um, a paper that uh was commissioned and that you published in the Lancet in 2024 about the colonial legacy, well, the yeah of knowledge platforms like the Lancet, and it's a great paper.
Speaker 3:And one of the examples you gave in there was about journals. I would say journals perpetuating certain styles of knowing and talking about knowledge and demonstrating knowledge and that sort of thing and being the methodologies that journals support and don't support. Now I've seen, I think, quite a big shift since I started doing qualitative research, which was, let's just say, realistically, 10 years ago, I would say in about 2014,. From memory, the BMJ would not publish anything, any qualitative research. That was their policy and I think that has changed a lot and their whole platform has changed a lot, for example. But I was really um interested in a line from from that article shared that said something about qualitative methods being essential for disrupting entrenched inequities, which I love.
Speaker 3:But I'm also going to say a but and I would love to hear your response to the but and this is partly um because I I do and read a lot of qualitative research and I'm um an editor of a journal where I read a lot of papers. I do notice a lot of qualitative research, trying very hard actually to bend to the sorts of privileged knowledge practices that come from sort of quanti stuff and, in particular, the fact that so many of these papers have limitation sections that are essentially, when it boils down to it, I'm sorry for doing qualitative research. I'm sorry this paper is not generalizable. It wasn't meant to be A lot of things like that.
Speaker 3:We got a terrific paper submitted to our journal, which I'll be as vague as possible because I don't want to call out these authors in particular, but it was from scholars in an african country who'd done a beautiful study about attitudes towards um selling uh genomic data, uh, and one of the one of the um limitations that they'd listed was that they didn't have any high-income researchers in their team. Like high-income country, I'm sorry researchers in their team, which was absolutely not a limitation of the paper. Trying to preempt what they preempt anticipated negative reviews from reviewers from high income countries. So I understand it.
Speaker 2:I understand it, but I'm really curious about your line about disrupting entrenched inequities around knowledge and how we can really disrupt those entrenched inequities around knowledge and if you've got anything to say around that I often try very hard and not always successfully to say to students who think that there's something wrong about quantitative research especially when we're talking about inequity and injustice and knowledge practices, and that there's something necessarily right about quantitative research. I'm often pointing out to them that you can use quantitative work for a lot of good. An example that I cited earlier is the one from the economics paper. It was classic econometrics analysis, right and that you can use qualitative research for very bad purposes. In other words, it doesn't match in that way.
Speaker 2:The point we were making in this article, however, was in part to the Lancet but also in part to journals who have their origin in biomedicine and who have, quote-unquote, become some kind of public health, global health journals who still behave as if biomedical methods and standards of rigor apply beyond biomedicine and, as a result, will not publish qualitative research because it just doesn't align in that way. When you and this, I'm sure, is published enough knowledge to say, if you ask the editor of the Lancet or editors at the Lancet why they don't publish qualitative work, they will say that they do. And we ask them okay, what do you mean? They say well, read the commentaries and the viewpoints. Okay, not in their mind. Qualitative research is not research, it's commentary on viewpoint.
Speaker 2:And I had a in the last two weeks. This is present because I was still editing this manuscript last night and this morning, so this is a real, present one. So we did a study. I won't describe it in full detail. We did a study and we submitted it as a research paper, structured in a research paper format, to a Lancet journal and it went through two rounds of reviews and it was being reviewed as if it was a systematic review, whereas it was a document analysis of a sample of document. And we kept arguing back and then we decided to reject it. So I wrote a very long, very long email, five pages, which I typed out in about 30 minutes to this editor and then the reply came. When it came it was was like I I see, I now see what you were doing and I think in fact, because we have compared what we submitted to another paper of mine which was much longer, that we hadn't described everything. And I said look, that paper allowed me 10 000 words, we are allowing it 4 500. Um, it's unfair to compare. And in the reply the editor said I think you have too many words, maybe you want to bring it down to 2,500 and publish it as a viewpoint. So exactly that thing came back and something I've heard many times before from editors of biomedical journals. And then we had to argue back and now it felt like a negotiation. We've agreed at 4,000 words, but still structured as a research paper. So it just gives you a sense of how that space works.
Speaker 2:Now you can't legitimize as research knowledge that isn't packaged in a particular way, and a lot of the work that people who are trying to change systems do will not come in that package. But then for those journalists to publish them, you have to then turn them into comments and viewpoints. So that was at the heart of that argument that there's something wrong here without your assignment. And it hasn't changed the evidence that just last week, even though they published this piece, because it's a Lancet journal that I'm talking about. So there is that problem in the field, and you said that things have changed over the last 10 years.
Speaker 2:I would say my suspicion and I may be wrong, but my suspicion is that we've had many more journalists in the last 10 years, so there are many more places for qualitative research to be published, but I don't think that the sense of hierarchy that was there 10 years ago has left. We have the chance to publish now, but the places that didn't publish that before don't publish them now, mostly with the BMJ. So the BMJ, when they said that thing, they said 2014,. They've not gone back. We still don't publish qualitative research, although BMJ journals do, but the BMJ doesn't still, and I was part of a group of people who were trying to push back.
Speaker 2:I didn't co-author that piece, but I'll say to those who were writing the piece in response to the BMJ that what the BMJ is not telling me is that they suspect that qualitative research will attract less citation, that qualitative research will attract less citation and that it would negatively impact their impact factor, which would negatively impact their bottom line. So there is. So, whilst they will make the argument, you know in writing that this is about rigor, et cetera, et cetera, et cetera. It's only partly true. Of course, they think there's a rigor problem, but side by side, that problem is also this sense that maybe it won't be cited a lot. A trial will be cited a lot. Um, a multi-country trial, especially, will be cited a lot. So let's go to places, let's publish things that will be cited a lot, that will make our impact factor great, that will make people publish in us and advertise with us. So this whole chain of connections that link back to money that often isn't clearly articulated as part of the argument for this.
Speaker 3:Yeah, you're 100% right. And, of course, when you were talking about your document analysis, I was thinking oh, you know, you're going to need a long method section there and it's not going to fit in there. You could publish somewhere else. But then the whole point of publishing somewhere else is, as you have just beautifully made, that you then in a way opt yourself out of that particular style of high-impact knowledge, if you like. Yeah, like yeah, which you know pros and cons, yeah, thanks which to, I guess, segue to your book.
Speaker 1:it it seems that you're. You know, obviously this is part of your work and and but, and so it should be unsurprising that there's a connection, but just even at that high level of. So your book is called the Foreign Gaze Essays on Global Health, and it was published in 2024 by IRD and it is available, open access. So we will be linking to it. But in here in the introduction you talk about the way that the essays try to say something about gays in global health and, by extension, pose or standpoint and about the foreign in relation to the local um, and so I mean I'll be interested to hear you talk about what you mean by the foreign gaze and what it does.
Speaker 1:But just, I guess, on the back of that conversation around the sort of politics of um publishing and methods and those sorts of things, it also struck me and this is a quote from the introduction in relation to the essay the Uses of Knowledge, and in it you say it is one thing for the foreign gaze to shape the action of foreign actors acting at a distance.
Speaker 1:It is another to consider what it means for foreign actors, or even local actors, to disregard the local gaze and to me, in some of these sort of debates around, what kind of knowledge can be published, in what format, with what methods is tied in with that disregarding of the local gaze or, at least you know, putting very strong parameters and gatekeeping over what we can look at, how we can look at it and who gets to do the looking. But yeah, I'd be interested on yeah, I guess you know what you're trying to do with these group of essays. This concept of the foreign gaze and I must say the aesthetics and the cover is quite a striking image. I love it and I don't know if there's anything. You feel free to sort of take this where you would choose to, because I know you've spoken about your book quite a bit and maybe there's different things you'd like to emphasise that you haven't been able to.
Speaker 2:I feel I had to give a lecture about the book and it was the first time I was talking about the book last week in London and I couldn't it was hard for me to talk about the book. So the structure of the lecture was that I was going to pretend that I was a reviewer and I'm going to describe what I would imagine a reviewer might be picking up in the book things that I hadn't said explicitly but that perhaps I have suggested in the book, and the angle I took was that perhaps it's the book of a frustrated editor who is trying to say things that he couldn't say as an editor of a journal, and I think that's true about the book and hadn't struck me as true until I tried to find an angle as to how I was a reviewer of it. And it's true in the sense that a lot of the motivation for the book came from trying to say something I found difficult to say. There have been in a lot of global health, international development, literature, a lot of focus on authorship imbalance, and so the last 10, 15 years there have been and it grew a lot, I think in 2017, 18, 19, people sort of publishing different bibliometric analysis showing just how, even for research done in the Global South, authors from the Global South are hardly present. If they are present, they are often in the middle, without authorship positions, because in biomedicine and health, first and last, authors are the most powerful and so they often sort of sequestered somewhere in the middle typically, and that there was a need to write that and I agreed with that and I see that as necessary.
Speaker 2:But I also understood, just from my vantage point as an editor, that even if we were to achieve that balance in authorship, there's a good chance that we wouldn't have achieved anything or achieved so little of consequence. And I felt that impact because I also knew and saw many manuscripts that I knew that the research question was what a funder wanted or was what was calculated. With a journal, a high-impact journal we want to publish, such that even when the lead author is from Malawi and that study was conducted in Malawi, I just felt so what, so what? And there were many manuscripts like that that I knew that this is for the foreign gaze, in that sense that this is not speaking to anything substantially relevant locally, and I want you to draw attention to that problem, that I agree that we ought to fight this battle of authorship, but let's not win a victory that will be meaningless. In other words, let's fight a more substantial battle than this one. Let's fight a serious battle, which is a battle about substance and that if we could get the substance right, we will get the authorship right. That the authorship is just a symptom of something else. Let's not treat a symptom, let's not fight it by symptom, let's fight about the real thing, and so hence the idea of the foreign gaze, which is this idea that there's something here that is directed outward and directed at power in ways that appeal to power, not challenge it, in a lot of how, standards, of prestige and of ideas of impact, what is publishable, what is rigorous, etc. So I wanted to place that as an issue on the table that we thought about at the same time as thinking about authorship and things like that. So here's the idea of the foreign gaze, and then, of course, the corollary, which is the post, which again is this I was thinking a lot in coining that this person who is local in a place like Malawi but directs their attention internationally to add power in this way, or someone who perhaps may be British but is in Malawi and is able to assume a local course and is able to sort of imagine themselves into that and direct their attention to the local gaze. In other words, I'm also very keen not to make this seem like fixed positions right that we as human beings have the capacity to be more than one thing and to be able to imagine and I was using Hannah Arendt's concept of representative thinking, so that was where this came from and of course, when you think more about that, you also start to abstract that into what can be foreign, even within Malawi. In other words, there are actors in Malawi in the health system, in the education system, who are foreign insofar as they are so powerful that they are disconnected from the realities of people who suffer by marginalized there. So there's also the foreign case even within a particular location. So foreign is not just a physical, geographical thing, it could also be a social thing. And then thinking about how foreign relates to local, even within spaces like that.
Speaker 2:And you mentioned the cover page. I'm going to comment on that, I will stop. It was. It's a.
Speaker 2:It's a picture from 1891 of two South African boys. They were members of a choir that went from South Africa to London, to England, not just London. That picture was taken in London to perform and raise funds to build a technical college for black people in the part of South Africa. So they were in London and there was a choir of everyone else was an adult except these two boys, and it was the period when photography was still a thing that people you know that you had to organize to do so.
Speaker 2:The London Stereoscopic Society came to one of them to take pictures of them and they took pictures of the adults, and the pictures of the adults were just consistently boring. But the pictures of these two boys, all their pictures, were just great in a sense in which it felt as if they were being shown as full human beings and the adults were being shown as stereotypical Africans. They were made to wear skin of animals that you can't even find in South Africa. It's crazy. If you Google you'll find the pictures. But all these two boys was always really, really lovely. And there's this shot that the photographers staged. It's a staged photo of the two boys, one sitting down posing for the gaze of the other, shot through the camera, and I thought that was a nice encapsulation of the framework that I was using in the book as the cover picture.
Speaker 1:Yeah, it's lovely. So, yeah, thank you, thanks for those reflections. That's, you know, the cover and the story behind it is really it's good to know more of that backstory and I'll be interested to see the other pictures because they do sound disturbing. Just, I guess you know we are running out of time so we'll have to finish up, but I like what you were saying about the foreigner and the foreign gaze can even be, I suppose, local to a situation because they're now removed from, maybe, the topic at hand, that they and I think you know, like so much you know of these sort of uh, so much of the work that's trying to correct past wrongs or past um, uh, um, I don't know, trying to think of a better word than just saying pass wrong. So it's more than that.
Speaker 1:But just, I guess trying to correct these sort of epistemological and ethical and ontological limitations in the way that we interact with other human beings relate to so much of just being a good human being in the way that, whether you're doing research, whether you're a policy person or, and so just this is a rambly way to get to the way that that idea of the foreigner struck me when, just this week, I was needing to give some advice to a student who was making a decision and I was able to sort of think, well, I had to make similar decisions to that, but this was 20 years ago and now I'm in, in a sense, a foreigner to that decision, like I don't know those same material pressures that this person is sort of deciding with cost of living and all of those sorts of things and how to make an education, how to make a decision about you know what education path to pursue, and so it does, I think you know.
Speaker 2:Coming to the context of you know, health, research and where people are just being aware of that, that, yes, we may have had that local knowledge at one point and we may have had that experience, but we're now significantly removed from that, either temporarily, spatially or economically, and being aware of that, yeah, and a word I use a lot in the book was distance and, as you were saying, it could be temporal or spatial, from a particular issue or a particular location, and also then what that distance does to our ability to understand, to really understand that thing and to see it in its full complexity, and how very often the research that we do because in part the way research, again, how rigor is conceived almost requires that we simplify something that is complex and then we are also distant from that thing, so we even further simplify it to the point of meaninglessness.
Speaker 2:And I was trying to draw that point that it's one thing, as a researcher, because of the privilege that comes with being a researcher, that we are distant from the reality and the audience to which we often are trying to speak, the gaze, is also really distant. It's foreign in that sense, and the ideas of that audience about what is rigorous and what is good compels us to oversimplify it. A lot of the industry of research for health, equity or justice or what we call global health, has been simplified and stripped of context, social and political to the point of pointlessness.
Speaker 1:Well, thank you so much for coming on. It would be good to have you on next time as well. I want to talk about the first essay in the world, but not of the world. I want to talk about, like, yeah, the first essay In the World, but Not of the World, like, I think, the reflection on that Bible verse from John, gospel of John, and again this sort of relationship between in and out and distance and space. Like yeah, there's so much to pick up on from your book.
Speaker 2:We'll listen to this podcast and we'll read the book. And who knows the Bible? Almost every chapter in the book has a phrase that is biblical. So if you really know the English Bible, you will see phrases from the Bible throughout Excellent.
Speaker 1:Well, I look forward to talking with you more about that at some other point.
Speaker 2:Thank you.
Speaker 1:Thank you very much. Yeah, I'm sorry, thank you. Thanks for watching.