Says who? Northern ventriloquism, or epistemic disobedience in global health scholarship

Abstract

Scouring a bookshop in Havana, Cuba, I came across Olive Senior's poem Colonial Girls’ School.1Senior O Colonial girls school.in: Ellis K Poetas del Caribe anglophóno. Casa del las Américas, Havana2011: 105Google Scholar It teleported me to my mother's and aunts’ musings about their colonial girls’ schools. Borrowed imageswilled our skins palemuffled our laughter […]dekinked our hairdenied our sex in gym tunics and bloomers […]yoked our minds to declensions in Latinand the language of Shakespeare […]How those pale Northern eyes andaristocratic whispers once erased usHow our loudness, our laughterdebased usThere was nothing left of ourselvesNothing about us at all […] I laughed in that salt-scented, balmy bookstore at the familiar dissent against “Latin declensions” and “bloomers”. Did I laugh with amusement? Inherited shame? Perhaps with relief that the stories of these women I loved, who made me, were not unique. I needed no interpretation of the poem. It spoke to my soul. I heard it in my blood. My ancestors arrived in South Africa from India as indentured labourers to harvest sugarcane when both countries were part of a British imperial hierarchy. The question “Global health 2021: who tells the story?”2The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar comes worryingly late given global health's extended infiltration into low-income and middle-income countries (LMICs).3Abimbola S The foreign gaze: authorship in academic global health.BMJ Global Health. 2019; 4e002068Crossref PubMed Scopus (105) Google Scholar As a woman of colour, a health worker, and a researcher, trained, practising, and living in a middle-income country, I applaud the editors’ resolution that “it is unacceptable for the gatekeepers and producers of knowledge to continue to mirror historical colonisers”.2The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar I worry that newly discovered, so-called editorial reflexivity will elevate journals above the oratory they pledge to uplift. Most global health university departments are in high-income countries (HICs).4Naidu T Southern exposure: levelling the Northern tilt in global medical and medical humanities education.Adv Health Sci Educ Theory Pract. 2020; 26: 739-752Crossref PubMed Scopus (10) Google Scholar Contemporary global health specialists and journal editors are predominantly white, male, and based in such countries. To hope for reflexivity in this environment is akin to someone looking in the mirror and hoping to see someone else. Epistemology is emerging as a key site of the critique of Euro-American bias in the geopolitics of knowledge.5Mignolo WD Prophets facing sidewise: the geopolitics of knowledge and the colonial difference.Soc Epistemol. 2005; 19: 111-127Crossref Scopus (27) Google Scholar Global health scholarship sustains its dominance through suppressing views from LMICs and through its methods of knowledge creation.5Mignolo WD Prophets facing sidewise: the geopolitics of knowledge and the colonial difference.Soc Epistemol. 2005; 19: 111-127Crossref Scopus (27) Google Scholar, 6Tuhiwai-Smith L Decolonizing methodologies: research and indigenous peoples. Zed Books, London1999Google Scholar The scholarly response from LMICs is threefold; to enunciate ideas from HICs back into HICs for traction in research and scholarship (which I designate as Northern ventriloquism); to resist this dominance by articulating local ideas in local spaces; or to subvert HIC dominance through scholarly insurgence (scholarly work that is in opposition to dominant scholarly or academic convention: epistemic disobedience). The challenge to the epistemological dominance by HICs has been initiated in health professionals’ education, with calls to level the “Northern tilt”,4Naidu T Southern exposure: levelling the Northern tilt in global medical and medical humanities education.Adv Health Sci Educ Theory Pract. 2020; 26: 739-752Crossref PubMed Scopus (10) Google Scholar dismantle “the master's house”,7Paton M Naidu T Wyatt TR et al.Dismantling the master's house: new ways of knowing for equity and social justice in health professions education.Adv Health Sci Educ Theory Pract. 2020; 25: 1107-1126Crossref PubMed Scopus (18) Google Scholar and pass “the microphone” to amplify voices from LMICs.8Wondimagegn D Soklaridis S Yifter H Cartmill C Yeshak MY Whitehead C Passing the microphone: broadening perspectives by amplifying underrepresented voices.Adv Health Sci Educ Theory Pract. 2020; 25: 1139-1147Crossref PubMed Scopus (4) Google Scholar These calls are important, but do not go far enough in moving women of colour from LMICs to a so-called promised land of transformed global health scholarship. The Lancet Global Health's commitment to gender equity and diversity has no matching commitment to intersectionality.9The Editors of the Lancet GroupThe Lancet Group's commitments to gender equity and diversity.Lancet. 2019; 394: 452-453Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar Yam and colleagues’10Yam EA Silva M Ranganathan M White J Hope TM Ford CL Time to take critical race theory seriously: moving beyond a colour-blind gender lens in global health.Lancet Glob Health. 2021; 9: e389-e390Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar recent challenge to the global health community for their apathy in not consciously addressing how multiple social categorisations—such as race and gender—interact and result in interlocking oppressions and privileges compels a corresponding depth and breadth of response from LMICs. Otherwise, I am just one in the latest generation of women of colour to have “willed my skin pale” and “yoked” my mind, hankering to be heard as I speak foreign ideas in a foreign tongue. Transnational feminist theory poses that feminist and anti-racist scholarship overlooks women of colour.11Narayan U Working together across difference: some considerations on emotions and political practice.Hypatia. 1988; 3: 31-47Crossref Scopus (146) Google Scholar, 12Moreton-Robinson A Talkin' up to the White woman. Queensland University Press, Brisbane, QLD2000Google Scholar, 13Anzaldúa G Borderlands/la frontera: the new mestiza. Spinsters/Aunt Lute, San Francisco, CA1987Google Scholar, 14Lugones M The coloniality of gender. Worlds & Knowledges Otherwise.https://globalstudies.trinity.duke.edu/sites/globalstudies.trinity.duke.edu/files/file-attachments/v2d2_Lugones.pdfDate: 2008Date accessed: May 18, 2021Google Scholar, 15Mohanty CT Under western eyes.Boundary. 1984; 12: 333-358Crossref Google Scholar Mainstream feminism privileges White women, and mainstream anti-racism privileges Black men.16Crenshaw K Mapping the margins: intersectionality, identity politics, and violence against women of color.Stanford Law Rev. 1991; 43: 1241-1299Crossref Google Scholar Anti-racist and feminist activism from HICs promote HICs’ perspectives. This irresistible provocation to tell the story invokes Audre Lorde's declaration that “it is better to speak / remembering / we were never meant to survive”.17Lorde A The collected poems of Audre Lorde. WW Norton and Company, New York, NY1978Google Scholar Epistemic violence is the active oppression by powerful structures to displace the marginalised from socioeconomic and knowledge-creating institutions to suppress their political voices. This exclusion incessantly erases contributions from LMICs to global knowledge creation.18Quijano AE Coloniality of power, eurocentrism, and Latin America.Nepantla. 2000; 1: 533-580Google Scholar, 19De Sousa Santos B Epistemologies of the South. Justice against epistemicide. Routledge, New York, NY2014Google Scholar, 20Mignolo WD The darker side of western modernity: global futures and decolonial options. Duke University Press, Durham, NC2011Crossref Google Scholar Health issues in LMICs might be the reason for which global health exists as a field.3Abimbola S The foreign gaze: authorship in academic global health.BMJ Global Health. 2019; 4e002068Crossref PubMed Scopus (105) Google Scholar As self-sanctioned champions of so-called tropical medicine, global health, and social medicine, scholars in HICs have shaped health in LMICs through subjective lenses, while claiming to be objective. Through objectified silencing, insiders from LMICs were treated as (re)sources from which HIC health researchers gleaned information to produce knowledge, validated and legitimised through so-called western scientific methods in universities in HICs.21Grosfoguel R The structure of knowledge in Westernized universities: epistemic racism/sexism and the four genocides/epistemicides of the long 16th century.Hum Archit. 2013; 11: 73-90Google Scholar This knowledge was then touted as universal, with scant regard for existing knowledge in LMICs.6Tuhiwai-Smith L Decolonizing methodologies: research and indigenous peoples. Zed Books, London1999Google Scholar, 15Mohanty CT Under western eyes.Boundary. 1984; 12: 333-358Crossref Google Scholar Regardless of how well intentioned, respectful, and reflective a researcher is in a foreign space, acting there imposes a researcher's world view and obscures local perspectives.6Tuhiwai-Smith L Decolonizing methodologies: research and indigenous peoples. Zed Books, London1999Google Scholar Marginalised voices are pre-emptively silenced when they are denied in advance.22Fricker M Epistemic injustice. Power and the ethics of knowing. Oxford University Press, Oxford2007Crossref Scopus (2705) Google Scholar In a recent submission to a journal in a HIC, I suggested that LMIC scholars unthinkingly adopt ideas from HICs; that decolonial perspectives should enter scholarship more directly; and that HIC technologies in medicine might obscure LMIC technologies. I received the following reviewers’ comments: first, “are there not people in the Global South who are perfectly willing to adopt Global North epistemologies? Is it really done in an ‘unthinking’ manner? Might they be using people from the Global North for their own purposes, regardless of epistemological design?”; second, “after almost 400 years of colonial presence (in South Africa), can we even return to a pre-colonial state?”; and third, “what about HIV/AIDS? Didn’t ‘we’ save ‘you’ with our technologies? (Exploring this topic might be a good example, should you choose to give a ‘case study’ for consideration)”. I intended to highlight epistemological oppression as the reason for which LMIC scholars resort to HIC epistemologies to be heard and accepted in dominant HIC spaces. My use of the word “unthinkingly” referred to LMIC scholars’ unquestioning acceptance of HIC ways of thinking, a position some theorists have described as “colonisation of the mind”.23Wa Thiong'o N Decolonising the mind. The politics of language and literature in Africa. James Currey, Oxford1981Google Scholar, 24Mignolo WD Epistemic disobedience, independent thought and decolonial freedom.Theory Cult Soc. 2009; 26: 159-181Crossref Scopus (633) Google Scholar, 25Bhattacharya K The vulnerable academic: personal narratives and strategic de/colonizing of academic structures.Qual Inq. 2016; 22: 309-321Crossref Scopus (45) Google Scholar I viewed the reviewer's need to question whether I was suggesting a return to precolonial times as simply condescending. The suggestion that I, as an African scholar, should legitimise my scholarship for the reviewer's approval through a case study valorising how HIC technologies (the reviewer's “we”) saved my middle-income country (the reviewer's “you”) from HIV and AIDS is prejudicial to me and my context (LMICs). These insidious and ostensibly unconscious tactics conspire to destabilise LMIC scholars, framing our scholarship as illegitimate. This kind of practice is at “the intersection of colonising discourses and microaggressions”.25Bhattacharya K The vulnerable academic: personal narratives and strategic de/colonizing of academic structures.Qual Inq. 2016; 22: 309-321Crossref Scopus (45) Google Scholar Silencing can be so pervasive that marginalised people smother their own testimony. I, along with countless other women of colour and health workers trained and practising in LMICs, have never considered submitting a paper to The Lancet Global Health. I have seen nothing of myself as a protagonist among the voices that this journal amplifies, and have not previously been welcomed in “frank, open discussion” to “offer solutions based on” my “own experiences”.2The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar When submitting manuscripts to HIC-based journals, I am worried that I might be imposed with a credibility deficit so severe that my testimony is quieted and my words not heard.26Dotson K Tracking epistemic violence, tracking practices of silencing.Hypatia. 2011; 26: 236-257Crossref Scopus (460) Google Scholar Another recently submitted paper on equity and social justice was desk-rejected because two other similar papers were published in 2020. By my deduction, the journal's editorial board were not my peers, and the emergent topic warranted more discussion than could be addressed in two papers. Sound academic reasons for the rejection might have existed, but “lack of representation within editorial workforces”2The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar and the addressed topics’ failure to strengthen current HIC narratives echoed deafeningly. Global health is academic, political, and economic in HICs. It is social, emotional, survival-related, and personal in LMICs. What is the meaning of me, a woman of colour and a researcher from a LMIC, being advised that my writing about race, gender, and social justice is too emotive and provocative? Is this one of the so-called unconscious biases that influence editorial decisions? For LMIC scholars and health workers, global health scholarship intersects with identity and is the everyday reality of working life. I am confounded to be a casualty of an editor's unconscious bias while he or she remains blissfully unaware or, perhaps, conveniently oblivious. They publish; I perish. The objectivity that HIC science venerates is far from my perspective as a health-care worker, researcher, and woman of colour from a LMIC. The aversion to the emotional and deeply personal in academic health scholarship is a decidedly male, HIC perspective that is nonetheless presented as universal truth.21Grosfoguel R The structure of knowledge in Westernized universities: epistemic racism/sexism and the four genocides/epistemicides of the long 16th century.Hum Archit. 2013; 11: 73-90Google Scholar Decolonial scholars refer to this viewpoint as the zero-point perspective, a position from which all perspectives emanate or are compared with, and fail.27De Sousa Santos B The end of the cognitive empire. The coming of age of the epistemologies of the South. Duke University Press, Durham, NC2018Google Scholar Northern ventriloquism occurs when LMIC scholars enunciate HIC ideas to access globally competitive grants and publish in high-impact journals. HIC scholarship uses its position to dictate structures and set priorities for the content, relevance, and timing of publications. Academic English is a key marker of academic authorship, so LMIC researchers might collaborate with HIC-based colleagues to “westernise the voice and the arguments” in their manuscripts to ensure publication in HIC journals.8Wondimagegn D Soklaridis S Yifter H Cartmill C Yeshak MY Whitehead C Passing the microphone: broadening perspectives by amplifying underrepresented voices.Adv Health Sci Educ Theory Pract. 2020; 25: 1139-1147Crossref PubMed Scopus (4) Google Scholar The dominance of English as an academic language and the suppression of indigenous and traditional world views coerces researchers to choose between publishing for local or global effect, which has important career implications, even in LMICs. As someone from a middle-income country who speaks English as a first language, I have a vicarious linguistic privilege in global health scholarship. Yet, I lament the sacrifice of an ancestral tongue that could have shaped my understanding of the world in different ways, if my ancestors had not been forced to concede it for social and educational traction in a colonial context. Northern ventriloquism results in researchers mimicking foreign poses for foreign ratification,3Abimbola S The foreign gaze: authorship in academic global health.BMJ Global Health. 2019; 4e002068Crossref PubMed Scopus (105) Google Scholar thus strengthening HIC dominance while extinguishing the LMIC episteme, a process that decolonial scholar de Sousa Santos calls epistemicide.19De Sousa Santos B Epistemologies of the South. Justice against epistemicide. Routledge, New York, NY2014Google Scholar Northern ventriloquism is a risky option that bolsters denial and negative judgment of local perspectives. Fanon28Fanon F Black skin, white masks. Grove Press, New York, NY1952Google Scholar explained that lactification, or becoming White in the context of race, offered potential advantages.Markers of so-called whiteness are not restricted to skin colour but also to class, where the Black person becomes proportionately White (and thus closer to being a real human being) in a direct ratio to mastering a language spoken by White people, acquiring culture typical of White people, and attaining a certain level of wealth. Black faces adopt White masks to be recognised as human in a White-dominated world.28Fanon F Black skin, white masks. Grove Press, New York, NY1952Google Scholar HIC dominance in global health scholarship pressures LMIC scholars to lactify their scholarly offerings. Decolonial theorists designate acts of resistance against dominant epistomologies as epistemic disobedience.24Mignolo WD Epistemic disobedience, independent thought and decolonial freedom.Theory Cult Soc. 2009; 26: 159-181Crossref Scopus (633) Google Scholar In practice, epistemic disobedience involves presenting and enacting diverse views to depose the zero-point perspective as a universal, objective measure of reality to one subjective view among many.28Fanon F Black skin, white masks. Grove Press, New York, NY1952Google Scholar Epistemic disobedience and delinking, through rebellion, opposition, and resistance, must be active resistance that is seen and heard.24Mignolo WD Epistemic disobedience, independent thought and decolonial freedom.Theory Cult Soc. 2009; 26: 159-181Crossref Scopus (633) Google Scholar Activists act in epistemic disobedience variously in counterpoint to the deleterious effects of epistemic violence, risking their being viewed as unprofessional, primitive, dangerous, and unscientific by dominant groups, and jeopardising their chances of academic promotions and access to research funding and high-impact journals.25Bhattacharya K The vulnerable academic: personal narratives and strategic de/colonizing of academic structures.Qual Inq. 2016; 22: 309-321Crossref Scopus (45) Google Scholar Epistemic disobedience is radical and, therefore, a threatening and disruptive action. Initially unfathomable, because it is contrary to dominant ideals, epistemic disobedience cannot be understood through dominant frames of reference because it emerges in resistance to, or to break with, the HIC canon.24Mignolo WD Epistemic disobedience, independent thought and decolonial freedom.Theory Cult Soc. 2009; 26: 159-181Crossref Scopus (633) Google Scholar There are some requirements for this resistance to begin in global health scholarship (panel).PanelRequirements for resistance in global health scholarship•Editorial boards declaring their gender, racial, colonial, and ancestral privileges and experiences in low-income and middle-income countries (LMICs)•Authors claiming space to write with emotion about personal and local identity perspectives in global health•Supporting editors from diverse spaces with the administration of editorial work, while trusting, protecting, and advancing the value of their previously neglected racial, gender, historical, and personal perspectives in editorial decision making•Promoting abstracts in LMIC authors’ first languages and the Indigenous languages of locations where research is done•Establishing multiple platforms and methods of constructing and presenting research and findings within global health scholarship•Relieving LMIC scholars of the pressure to provide solutions to problems they did not create, offering instead an opportunity for dialogue on equal terms •Editorial boards declaring their gender, racial, colonial, and ancestral privileges and experiences in low-income and middle-income countries (LMICs)•Authors claiming space to write with emotion about personal and local identity perspectives in global health•Supporting editors from diverse spaces with the administration of editorial work, while trusting, protecting, and advancing the value of their previously neglected racial, gender, historical, and personal perspectives in editorial decision making•Promoting abstracts in LMIC authors’ first languages and the Indigenous languages of locations where research is done•Establishing multiple platforms and methods of constructing and presenting research and findings within global health scholarship•Relieving LMIC scholars of the pressure to provide solutions to problems they did not create, offering instead an opportunity for dialogue on equal terms Northern ventriloquism stifles personal and local identity and the opportunity to radically restructure global health. Enacting epistemic disobedience poses the risk of further exclusion from a global stage. As a woman of colour from a middle-income country, I am sceptical of the resolve to bring the so-called promised land closer. Will there be anything left of ourselves when it comes? Contributors I conceptualised, conducted literature searches, and wrote this Essay. I declare no competing interests.