The foreign gaze : authorship in academic global health

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.

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.

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.

Many thanks to my spouse and to my friends and colleagues who listened to me talk about the ideas in this editorial as they developed and/or read previous drafts of the editorial - for their indulgence, their encouragement and their comments.