Chapter 2. The foreign gaze
p. 27-37
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“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 (1998a)
“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 (1998b)
1There is a problem of gaze at the heart of academic global health. It is a difficult problem to name. So I reach for the words of the African-American writer Toni Morrison. Replace the word “white” in the quotes above with the word “foreign”, and you may see what I mean. Better still, please read on. Without naming this problem, it is difficult to think clearly and holistically about imbalances in the authorship of academic global health publications – and by extension, the entire knowledge infrastructure of global health. These imbalances are about who gets to speak about and on behalf of the other(ed) across inequity lines, and on which platforms. Again and again, bibliometric analyses of authorship distribution show well-known imbalances (Kelaher et al., 2016; Chersich et al., 2016; Rees et al., 2017; Cash-Gibson et al., 2018; Schneider & Maleka, 2018; Boum Li et al., 2019; Hedt-Gauthier et al., 2019). 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 agendas), and those in middle-income and, especially, low-income countries (where the research is often conducted).
2It is tempting to proffer specific or direct solutions to imbalances in authorship with initiatives such as mandating journals, funders, universities and their governing bodies to include local authors (based in low- and middle-income countries); to change their academic promotion criteria so that foreign experts (based in high-income countries) can more readily give up choice authorship positions on work done in low- and middle-income countries; to provide resources to academics in low- and middle-income countries to engage more equitably in partnerships; to change the criteria for authorship so that more roles in the global health research process are recognised; and to increase the diversity of journal editorial boards with the expectation that the more diverse the editorial board, the more diverse the published authors (Boum Li et al., 2018, 2019; Hedt-Gauthier et al., 2018, 2019; Carvalho et al., 2018; Lancet Global Health, 2018; Bhaumik & Jagnoor, 2019; Nafade et al., 2019). In my view, these measures are often necessary. But I can’t help wondering if, without addressing the problem of gaze, they may result in us granting ourselves moral license. If the self-congratulation that will likely follow having these measures in place might make us excuse ourselves from addressing more fundamental issues.
3It took me time to name the problem of gaze. In conversations and in comebacks, I found myself unable to say what I wanted to say without a 15-minute preamble. Naming the problem required finding a language for it. We cannot talk about authorship or inequity in knowledge production without grappling with who we are as authors or the position or standpoint from which we write or produce knowledge (our pose), as well as for whom we imagine we write or produce knowledge (the gaze). In a field like academic global health that acts at a distance – physical and social – we must strive to distinguish where we stand (pose) and in relation to whom (gaze). I had to find these two interlocked concepts, and the more I thought about them – separate, combine, juggle and stretch them – the clearer it became to me that to proffer solutions to authorship imbalance in academic global health without considering pose and gaze is to fall for the allure of simple solutions.
4The concept of pose stems from the idea that one’s account or analysis of a social system or a social reality is rooted in one’s situated knowledge and perspectives (Harding, 1991). But as the German-American historian and philosopher Hannah Arendt argues, we are not prisoners of our pose or standpoint. In her words, it is possible to analyse a given social issue “by making present to my mind the standpoints of those who are absent” such that while doing so, “the more people’s standpoints I have present in my mind” and “the better I can imagine how I would feel and think if I were in their place”, then “the more valid my final conclusions” (Arendt, 1968). Arendt calls this disciplined practice “representative thinking”. The concept of gaze, the way I use it, comes from Toni Morrison; it includes the idea that one’s primary audience can be local, is ideally local, within one’s community, where the soil is fertile, where authenticity is reinforced. It is the sense that one’s audience is never inert. We speak differently based on who is listening, who we think is listening, who we wish would or want to listen.
5Just as it is possible to imagine oneself occupying a foreign pose – even if rarely done, for example, through Arendt-style “representative thinking” – one can also write for a foreign gaze by imagining what it is like to listen from afar. One can imagine what an outsider is like, what it is they want to hear, and play to it. I have had cause to occupy a local pose and sometimes combine it with a foreign pose. I have also had cause to address myself to a local gaze, and often to a foreign gaze. As an academic, I have had to manage my own shifts in pose and gaze, working as a local researcher and a foreign researcher (Gilmore, 2019).
6The structure of this essay is based on a constructed “ideal” (Appiah, 2017) of how things might be if there were no international health research partnerships; how things must have been when (circa late-19th to mid-20th century) many of the places that are now high-income countries experienced significant improvements in health and equity (Cutler et al., 2006); i.e. an “ideal” of local people writing about local issues for a local audience. It is the kind of ideal that Toni Morrison might prescribe for art and literature. But here I deploy this “ideal” not necessarily as a prescription, but more as a heuristic device. By applying this sense of “ideal”, I wrestle, rhetorically, with three questions that give me pause whenever I consider solutions to imbalances in authorship, solutions that require mandates and strictures. These 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?
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7The first question – What if the foreign gaze is necessary? – stems from the notion that the requirement for balance in authorship in global health research 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. Does it matter if the authorship of such a paper is skewed towards foreign experts or entirely by 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 always holds. But a situation in which the foreign gaze is necessary should be an exception. And so, such papers should be labelled by the lead author (“written with a foreign pose for a foreign gaze”), with the justification for this exceptional choice of pose and gaze clearly and visibly articulated. Perhaps in a box, just below the list of authors, or as a footnote, or next to the conflicts of interest statement.
8Let’s explore one such potential scenario. Take, for example, a hypothetical paper written by a foreign expert about burial practices in West Africa. The author was deployed as part of a team of anthropologists to support efforts to address an Ebola outbreak. Through this anthropological work, the academic helped the “foreign-led” team in West Africa to make sense of local practices, thus contributing to more effective strategies for adapting burial practices in the wake of the Ebola outbreak (as the burial of loved ones who died from the infection is often a channel for contracting the virus). The audience for whom the paper is written is likely other anthropologists who perform similar services in other countries while working as foreigners: a role that may not exist if all such response teams were led by local experts – if every country had the capacity (especially, the funds) to respond to their own outbreaks.
9In an “ideal” scenario – in which 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. It is “written with a local pose for a local gaze”. Here is a worthwhile thought experiment: how does 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 (Figure 1): for example, “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, helping academics – foreign and local – to be more deliberate in their choices and attitudes, and helping readers to better situate the purpose of a paper.
10This authorial reflexivity could give permission to the foreign expert, who, recognising the limits of what they can see or understand, chooses to write primarily for other foreign experts. It can also 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 in the location of the outbreak – foreignness could be defined by familiarity, by ethnicity, race, caste, gender, geography, socioeconomic status, or the issue in question. The declared authorial reflexivity could also help readers or bibliographers understand the reasoning behind the pose and gaze. This might be that there is no local capacity available, that the pose and/or gaze does not matter, that the message is best suited for a foreign audience, or that the lead author knows too little to have anything of value to say to local experts.
11The longer form of the second question – What if the foreign gaze is inconsequential? – is as follows: What if it is indeed the local (rather than the foreign) gaze that is consequential? To explore its implications, let’s return to our foreign anthropologist in West Africa, but one who chooses to write primarily for local experts – i.e. “with a foreign pose for a local gaze” – in an effort to approximate the ideal “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 (MoChridhe, 2019), but would contain publications addressing research questions and policy issues that 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 (Sgrò et al., 2019), many of them appearing in outlets that may be deemed non-traditional or “predatory” (Shen & Björk, 2015; Frandsen, 2017).
Figure 1 | The authorial reflexivity matrix with potential effects of combinations of local and foreign pose and gaze.
Local Gaze | Foreign Gaze | |
Local Pose | “Ideal” | Corrupting? |
Foreign Pose | Consequential? | Necessary? |
12How consequential is the 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, because local processes are responsible for many of the historical improvements in health and equity (Szreter, 1988; De Brouwere et al., 1998; Fairchild et al., 2010; Bhatia et al., 2019; Medcalf et al., 2015). For example, there is as yet no association between the density of papers (archived in international databases of academic publications) on universal health coverage from a country and the attainment of universal health coverage by that country (Gheorghe et al., 2019). What gets written for the foreign gaze reflects the appetite of the foreign gaze (Storeng & Béhague, 2017; Chambers, 2017; Roalkvam & McNeill, 2016; Jerven, 2018; Rajkotia, 2018; Bédécarrats et al., 2019; Storeng et al., 2019), which is more attuned, in the words of the 20th-century British writer and literary scholar C.S. Lewis, to “the surgical” than to “the organic” (Lewis, 1943).
13In his book, The Abolition of Man, C.S. Lewis describes the difference between “alteration from within” (or organic change) and “alteration from without” (or surgical change) (Lewis, 1943). He illustrated surgical change with the example of “a theorist about language” who chooses to “approach his native tongue, as it were from outside, regarding its genius as a thing that has no claim on him and advocating wholesale alterations of its idiom and spelling in the interests of commercial convenience or scientific accuracy”. He juxtaposed this with the example of organic change by “a great poet, who has ‘loved, and been well nurtured in, his mother tongue’” whose “great alterations […] of the language are made in the spirit of the language itself” such that “the language which suffers [or undergoes radical changes] has also inspired the changes”. In our efforts to achieve health equity, as in other efforts to bring about social change, it is much easier to see and bring about “surgical” change (as the agents of change are tangible, short-term, often external), than it is to see and bring about “organic” change (as the agents of change are diffuse, long-term, typically internal). Yet attaining a goal such as universal health coverage requires an organic process. As people who do academic global health, we must get better at recognising and explaining long-term processes of organic change (Rosling et al., 2018).
14Papers 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 – the “surgical”. But evidence and insight from several low- and middle-income countries suggest that long-term change is brought about by local organic processes, policies and dynamics: for example, the role of women’s empowerment in explaining long-term change in child health outcomes (Keats et al., 2018; Nguyen et al., 2018; Rahman et al., 2019; Dwomoh et al., 2019). It is unfair, and even misleading and colonial, to pay undue attention to the foreign gaze. 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.
15We must rethink our attitude to “local” journals and take some responsibility for why many local experts publish in “predatory” journals. If we prioritise 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 found legitimate peer-reviewed journals instead. 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: e.g. because it is a multi-country study, the findings are irrelevant to a local audience, the funder’s expectations, the journal’s impact factor, or for promotion, grants and prestige.
16The third question – What if the foreign gaze is corrupting? – has particular resonance for me and for many people I know who work primarily from a local pose. To explain what I mean, let’s return once again to our anthropologist, but this time it is a local anthropologist who is a local expert that chooses to write primarily for a foreign audience. As pose is often determined by the gaze of the spectator, a 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. The local expert makes a trade-off – between on the one hand, the need to tell it like it is, and on the other, an effort to globalise the use of language, to make the 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 (for example, about local burial practices) can be lost, especially for the local audience.
17The foreign gaze can make a local expert write like an expatriate. This tendency is often detectable in the language of local experts who work closely with foreign experts, or in post-colonial literary fiction written for the foreign gaze (Adesokan, 2012). 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 also risks losing their own sense of reality; the sense of complexity and of multidimensional reality that is often necessary to solve problems in global health (Abimbola, 2018). An additional corrupting influence of a preoccupation with the foreign gaze is that it can distract local experts from engaging in the often consequential and often non-academic conversations in their own setting, some of which are not in English. These conversations should be at the centre of academic global health discourse, but unfortunately are often not taken as seriously (Saha et al., 2019).
18The most important conversations about health systems in many low- or middle-income countries do not make their way into peer-reviewed journals (whether local or foreign), and, perhaps, neither should they. I glean them from email listservs, local newspapers, local blogs, local radio, WhatsApp groups, and even on X (formerly Twitter). It would be colonial and anachronistic to expect or require that such conversations be had in foreign journals, which many of the participants do not read, and should not be expected to read. 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 get into the academic global health literature, channels that can help people who are foreign recognise, amplify and draw insight from local conversations without asking those conversations to move, extractively, to foreign platforms.
19To make global health truly global is to make global health truly local. Perhaps what our local anthropologist who seeks to or must, for various reasons, write for a foreign gaze might 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 (e.g. a local newspaper, journal or blog, perhaps in a local language) (Saha et al., 2019). In the version written from a foreign pose for a foreign gaze, the local expert might 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 might do this in a statement, as part of the declaration on authorial reflexivity, just below the list of authors, or as an extension of the conflicts of interest statement.
20There are times and places in which it may be unwise to be so honest or to even focus on the local gaze. Writing that denounces government violence or human rights violations can better serve their local purpose with a foreign gaze. Publishing such denunciations in a foreign journal for a foreign audience can strategically attack the credibility or image of the government in question. The pressure exerted can be more consequential than a local debate or exchange. When direct criticism of government action or inaction is involved, opting for a foreign gaze can be the opposite of corrupting. Externally directed writing can also trigger strong local debate and denunciation of the silencing and repression of local voices. In either case, the foreign gaze is justified and necessary. There are times and places in which often for colonial reasons, the best way to be locally consequential, to obtain a place in the local conversation where consequential decisions are being made, is to cultivate and sustain strong foreign networks and visibility, including through publications. There are also features of a social system or a social reality that you only see clearly when you have to explain them to an outsider; or when an outsider tries, even if unsuccessfully, to explain them to you or to fellow outsiders.
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21Concerns about imbalances in authorship are a tangible proxy for concerns about power asymmetries in the processes involved in – and the benefits of – knowledge making, use, and sharing 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. Discussions on authorship in academic global health are an opportunity to have the necessary conversations that go beyond mere representation in lists of authors. We can trigger these conversations by engaging in open self-reflection: that is, reflexivity, a practice about which much can be learned from critical and Indigenous anthropologists (Jacobs-Huey, 2002; Smith, 2012; Harrison, 2011). These self-reflections can be aided by the authorial reflexivity matrix (Figure 1), as we explore and seek to be explicit about 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 less than ideal situations more consequential, and our choices less corrupting.
22What makes one’s pose or gaze local or foreign is not only defined by a physical place, and it is not static. Although I was born, raised and educated in Nigeria, the meaning of “somewhere else” could include a part of Nigeria that I am unfamiliar with. I grew up in Owo, a peri-
urban town in southwestern Nigeria. That may be the only place where I am truly local in a physical, geographical sense. I have moved around a lot since then. In many ways, I am more foreign to many big cities in Nigeria than I am to Sydney in Australia, where I currently live (perhaps more so, the longer I live in Sydney). The distance that makes us local or foreign can also be social. I feel “local” to middle-class Nigeria across much of Nigeria. In many ways, I am “foreign” to the realities of Nigerians living in poverty, except perhaps in Owo because of my mother’s pro bono practice as a community midwife. But even then, I saw them in my childhood through a particular lens, and certainly not fully in the same way they see themselves. I am “foreign” to the realities of most women, LGBTQIA+ people, Indigenous Australians, Swedes, upper-class Nigerians, Nigerians raised in Muslim homes, etc.
23The awareness of my foreignness is a cautionary stance. It reminds me to tread gently, to be slow to form opinions, to hold my opinions lightly, to defer judgement as long as necessary – or forever. It is a caution against being “colonial”, especially towards people in relation to whom I have more power. Not being cautious or humble about the limits of one’s pose is at the root of colonial love. There is often a lot of introspection involved in knowing one’s status, whether foreign or local in relation to a place or issue. One’s pose cannot be easily determined by someone else. Our pose in relation to a place or issue is ours to decide and declare. While it is possible to do “representative thinking” à la Hannah Arendt, to imagine oneself into “the standpoints of those who are absent”, and to imagine how one might feel, think, and interpret if one “were in their place”, it is a difficult thing to do and often impossible to do well. No matter how expansive one’s imagination or self-awareness, it is always limited. Hence the need to carry out reflexivity in the open.
24The implications of the three questions explored in this essay are inescapable, just as the foreign gaze is inevitable. In a relentlessly globalising world, our destinies are so interlinked that the reasons for and solutions to problems in global health can be local or foreign. Even within a local space, those who get to be in a position to work towards health equity, to do global health, do it from a place of relative privilege, a foreign place. But in a world of power and knowledge asymmetries, we see differently and understand differently; and too often, the power to act is not directly proportional to the knowledge upon which to act (Abimbola, 2016). There will always be gaps between what local experts see and what foreign experts can possibly see (Gilmore, 2019). But having 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 knowledge practices. The proposed reflexivity statements in publications can be a starting point, in the hope that, in this case, sunlight may well be the best disinfectant.

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