Introduction
p. 7-12
Remerciements
To S.O., for example.
Texte intégral
“Something changed when Africans began to take photographs of one another: you can see it in the way they look at the camera, in the poses, the attitude. The difference between the images taken by colonialists or white adventurers and those made for the sitter’s personal use is especially striking in photographs of women. In the former, women are being looked at against their will, captive to a controlling gaze. In the latter, they look at themselves as in a mirror, an activity that always involves seriousness, levity, and an element of wonder.”
Teju Cole (2016)
1There is growing disquiet in the field currently known as global health – about its knowledge practices, its academic arm. This book is about one of the reasons for that disquiet, a reason that is easy to ignore and difficult to name: which is that the field’s knowledge practices are constructed for a powerful audience. An audience that is typically foreign – in the physical and social sense of the word “foreign”. What that audience wants often shapes how those who address it behave, and what they can – or choose to – see or say. Imagine the scene of a photoshoot. The photographer is behind the camera. The person being photographed strikes a pose, calibrated to the photographer’s gaze. The photographer cues, shoots from different angles. The photos reflect the poses struck in response to the gaze. They reflect the relative power of the person striking the pose, and the person whose gaze is shot through the camera. The photoshoot is co-produced, staged perhaps, on a platform.
2Now imagine a third party observing the scene of a photoshoot. In each essay in this book, I describe, as an observer, scenes of an academic global health photoshoot. Each essay attempts to say something about gaze in global health – and, by extension, pose or standpoint – and about the “foreign” in relation to the “local”. Each essay is a photoshoot of a photoshoot, some of which include the platform on which the photoshoot is staged. I observe and take notes from varying standpoints. I shift around to see and shoot from different angles. Each essay presents reflections on my experience of academic global health, refracted through the explanatory lens of the foreign gaze. But what I have tried to explain here can be done differently, through other lenses – and has been and will be by others. This is my lens: your audience has power (the gaze), and where or how you stand in relation to it (the pose) shapes what you can – or choose to – see or say. Shot in this way, some features of global health are easier to see than if shot differently. Each essay presents pictures. This collection presents several photoshoots.
3Any book on global health must first get one thing out of the way: what global health means, or should mean. In the first essay, “In the world, but not of it”, I use personal and world history to show how I make sense of “global health” as action “at a distance”. To define the foreign gaze, one must establish the markers of distance: when or why an actor may be deemed foreign or local to a place or an issue. The second essay, “The foreign gaze”, attempts to do this. It maps how the foreign gaze often neuters the global health literature. The foreign gaze has an appetite for simplicity. It makes people “at a distance” think and act as if complex social systems and realities were simple. The third essay, “Evidence as cliché”, reflects on the harmful effect of oversimplification, especially as it relates to learning in health systems. In the fourth essay, “Thinking in two triangles”, I use stylised scenarios from my personal and others' experience to show how one might discipline one’s thinking about the governance of a health system when positioned or acting “at a distance”.
4The fifth essay, “The uses of knowledge”, maps the users of knowledge within any unit of social organisation. It maps one set of proximate knowledge actors and another set of actors that are “at a distance”. It also makes the case for using the principle of subsidiarity to guide relations between proximate and distant knowledge actors – or between local and foreign actors. It is one thing for the foreign gaze to shape the action of foreign actors acting “at a distance”. It is another to consider what it means for foreign actors or even local actors to disregard the local gaze. Using personal and world history, the sixth essay, “The dignity of the spectator”, explores what it means to not hold in high regard the proximate audience, the local gaze; to violate their dignity as knowers. The seventh essay, “To be wronged as a knower”, uses a constructed narrative from personal history to examine the complexities of speaking up or talking back to an audience that represents the foreign gaze, an audience that may have violated one’s dignity as a knower.
5Each of the essays collected in this book contends with the power of the foreign gaze. But the essays have something else in common: the conception of each began with an image, a picture. “In the world, but not of it” began with the image of distance, even in the context of some form of intimacy. “The foreign gaze” arose from the idea of a photoshoot: understanding a person’s pose as a performance for a certain gaze. “Evidence as cliché” was imagined as a chat in which a speaker deploys a thought-stopping cliché, and the wise listener, rightly, rolls their eyes. “Thinking in two triangles” began with the image of a triangle, with two nodes interacting within a context created by the third node. “The uses of knowledge” began rather as an image of four circles; two big circles proximate to action, and two small circles distant from action – the big ones are much more important, but the small ones get all the attention. “The dignity of the spectator” emerged from an image of the parable of the six blind people and the elephant. “To be wronged as a knower” originated from the image – in fact, a series of images – of giving a talk to a suspicious, defensive, potentially dismissive audience.
6These essays all began as an attempt to explain an idea to students, colleagues or friends, or with an invitation to give a talk or write an article. “The foreign gaze”, “Thinking in two triangles” and “The uses of knowledge” first appeared as editorials in BMJ Global Health; and “Evidence as cliché” first appeared in the CODESRIA (Council for the Development of Social Science Research in Africa) Bulletin. These four essays are republished here under slightly different titles, and with the chance to return to them, somewhat different text. An earlier version of “To be wronged as a knower” was delivered as my keynote address, invited by Chisomo Kalinga, at the 2021 “Finding Joy in Healthcare in Africa” symposium organised by Medical and Health Humanities Africa. A version of “In the world, but not of it” was delivered as my inaugural lecture as the 2020–2022 Prince Claus Chair in Equity and Development at Utrecht University in the Netherlands. An earlier version of “The dignity of the spectator” was delivered as the 2022 annual lecture of the Warwick Interdisciplinary Research Centre for International Development (WICID) at Warwick University in Britain, which was hosted by Oyinlola Oyebode. The conclusion was first delivered as a public lecture in my role as the 2023–2024 Radulovacki Visiting Scholar in Global Health at Northwestern University in the United States.
7I am grateful to the many people who have asked me to speak or write an article, or listened to me voice ideas as they developed, read or critiqued my work, or suggested additional references – in social settings, in classrooms and seminar rooms, on X (formerly known as Twitter), by email, or on Zoom – in particular, Onikepe Owolabi, Joni Lariat, Alice Bayingana, Jumoke Adebayo, Kenneth Yakubu, Nimi Hoffman, Dorothy Drabarek, Pip Crooks, Aliki Christou, Emilie Koum Besson, Sarah Bernays, Supriya Subramani, Himani Bhakuni, Thirusha Naidu, Vikash Keshri, Veena Sriram, Jaime Miranda, Madhukar Pai, Stephanie Topp, Valéry Ridde, Christopher Wright, Rochelle Burgess, Neha Faruqui, my spouse Oine Omakwu (who kindly tolerates my appetite for solitude), and our daughters Erin Joy and Kori Ene (who make writing more fun by agreeing to read my words out loud). The work presented in this book was done at the University of Sydney, Australia (on the lands of Indigenous peoples whose sovereignty over the place currently known as Australia was never ceded), supported by fellowship grants from Australia’s National Health and Medical Research Council and the Australian Research Council. I owe much to the combined wisdom of James Baldwin (1924-1987) and Toni Morrison (1931-2019), and my mother, Sola Abimbola (1954-2009). Their work and how they made sense of the world greatly inspired the essays in this book. Their example allowed me to think more clearly about what it means to define what one does in relation to the foreign gaze – and what it means to stubbornly resist that pull. Their example allowed me to ask with all seriousness: What does it mean for a society to see itself, organise itself, and make, use, share and value knowledge (including its own knowledge) based on terms defined from outside? What does it mean to take the measure of oneself, one’s soul, one’s destiny, on another’s terms?
8The current disquiet in global health has a rich antecedent. There is a long history of engagement with unfair knowledge practices by anthropologists and ethicists of global health and health systems (Adams, 2016; Closser et al., 2022; Pratt et al., 2017; Aellah et al., 2016). But this engagement has only recently taken the form of direct complaints about these practices and efforts to undo them (Aellah et al., 2016; Richardson, 2020; Kalinga, 2019). Articulating these concerns as complaints is a recent phenomenon even in global health (Naidu, 2021; Lancet Global Health, 2021; Hanson-DeFusco et al., 2024). Even more recent is framing them as epistemic injustice – or, more accessibly, as unfair knowledge practices (Bhakuni & Abimbola, 2021; Fillol et al., 2022, 2023; Fillol, 2022; Koum Besson, 2022; Bhakuni, 2023; Pratt & De Vries, 2023; Abimbola, 2023a; Abimbola et al., 2024; Burgess, 2024). Yet there is an established tradition of critical epidemiology in Latin America (Breilh, 2021) which, since the 1970s, has developed a critique of downstream analyses of health inequity, and promoted approaches to quantitative and qualitative analyses aimed at undoing unfair epistemic (and political) status quo. But as most of the literature is in Spanish or Portuguese, its spread elsewhere has, unfortunately, been limited. Literature in English on unfair knowledge practices has grown recently, much of it by scholars and practitioners from Africa, Asia and Latin America, including those in the diaspora (Abimbola et al., 2021; Sharma & Sam-Agudu, 2023; Lancet Global Health, 2023; Montenegro et al., 2020); but to date this is much less advanced than Latin American critical epidemiology. Work questioning academic global health in other languages is beginning to take off, but slowly. Scholars and activists writing in French, for example, have begun to engage in it more deeply and to ask others in their orbit to take unfair knowledge practices in global health more seriously (Ridde et al., 2023). Change will require a critical mass of people working in French, as in other languages and in other places. The essays in this book were written and are collected here to help build that critical mass.
9This moment in academic global health – and perhaps also in its parent fields of public health and international development (or is it their sibling, cousin or rebellious foster child?) – places the focus of change on those who do it, not only on a vaguely defined set of actors external to the field. Unfair knowledge practices in global health are as much about the role of we academics and the institutions (the rules, norms, expectations, conventions) we tolerate, accept, build and uphold, as they are about the role of other actors and institutions. This long overdue shift in focus puts the onus for transformative change on all of us involved in academic global health and its adjacent domains of research and practice. We cannot fulfil our commitment to health equity globally – to “global health” the mission, not the field (Krugman, 2024) – without a careful self-examination and without being clear about what ails us. Which is that we tolerate, accept, build and uphold institutions that default to inflicting epistemic injustice on marginalised others – choices and tendencies which are powered by colonialism and other sources and forms of inequity everywhere. We have to be clear about what needs to change and why. We are, many of us, so immersed in the field, so educated and socialised into its flaws, so beholden to its antecedents, that we allow ourselves too little room to resist, or to imagine alternatives.
10These essays offer ways to think and act against the potential for unfair knowledge practices – the epistemic injustice – inherent in academic global health. The aim is not to be prescriptive, but to show why many of our accepted knowledge practices are unfair, and to suggest how we might entrench more just knowledge practices. How we might transform academic global health. The Yorùbá caution against being overwise: Bí ọ́gbọn bá fo àràbà, t’óbá fo ìrókò, ẹ̀yìnkùlé agọ̀ náà níí já sí. (“When wisdom jumps over the tall àràbà tree [~75 m] or jumps over the tall ìrókò tree [~50 m], it lands in the backyard of folly.”) I take this as a caution against epistemic hubris; one that our field must heed. The current disquiet in academic global health is long overdue, and I hope it persists long enough and goes deep enough to transform the field. So I will risk being overwise this once, and predict the coming of a field that will have the nickname: “the field formerly known as global health”.

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