Tag Archives: Global Health

The Foreign Gaze: A Review

Seye Abimbola’s book, The Foreign Gaze, is a thoughtful and often elegantly written account of how power distorts knowledge production in global health. Drawing on personal experience and philosophical insight, Abimbola introduces the concept of “the foreign gaze” to describe the way researchers, particularly from low- and middle-income countries (LMICs), shape their work for external audiences—northern donors, editors, reviewers, and institutions. The result, he argues, is a system where knowledge is produced not for the people it is intended to serve, but for those who control its global circulation and validation.

The strength of the book lies in its clear moral purpose. Abimbola calls for greater attention to “pose” (the standpoint of the knower) and “gaze” (the intended audience), and argues for an ethic of epistemic justice—where local actors are not just included in global conversations but are recognised as authoritative producers and users of knowledge in their own right. He speaks with conviction about the daily indignities of exclusion and marginalisation, and the ways in which academic global health often fails those working at the front lines of health systems.

And yet, for all its rhetorical clarity and moral force, The Foreign Gaze is ultimately an unbalanced critique. It targets external systems of authority—foreign reviewers, northern journals, donor agendas—without seriously interrogating the internal dynamics of epistemic dependence within LMICs themselves. In doing so, it offers a partial, and sometimes evasive, account of the problem it sets out to name.

First, the book is morally lopsided. Abimbola presents the Global South as the passive object of northern scrutiny, not fully acknowledging how deeply southern actors participate in, benefit from, and scaffold the system he critiques. Nor does he describe the effort that Global South actors will go to, to be seen by the Global North. Ministries of health design policies to satisfy donor templates. Researchers tailor proposals to align with northern funding calls. Academic careers are built on publishing in northern journals and securing foreign recognition. These are not the actions of helpless victims; they are rational and strategic choices made within unequal systems. Yet Abimbola offers little analysis of this internal complicity and treats the relationship as Manichean: colonial = bad, indigenous = good.

This lopsidedness extends to his treatment of knowledge. At key moments, he blurs the line between affirming the dignity of knowers and valourising the truth of what they claim to know. He rightly insists that people must not be dismissed because of their institutional distance from power—but he often slides into assuming that local practices are not only morally meaningful but epistemically equivalent to biomedical science. This argument is especially evident in his discussion of Nigerian group antenatal care, which he treats as if it should be shielded from empirical evaluation, even while dismissing external attempts to rigorously assess it. The suggestion is that foreign testing is not just misplaced but offensive.

Yet this defence reveals a more profound contradiction. The Foreign Gaze claims to champion epistemic justice but curates who counts as a knower. Abimbola elevates midwives, grassroots health workers, and insider academics, but gives little attention to the knowers within communities whose influence may be coercive, regressive, or misinformed. The dignity of knowers, in his account, is reserved for those whose knowledge can be rendered morally resonant. In this way, the book replicates the very asymmetries it aims to dismantle: it replaces epistemic exclusion with selective inclusion, rather than with principled universality.

Though Abimbola does not argue for relativism outright, his privileging of proximity lacks an accompanying framework for testing or contesting local knowledge. In practice, this leaves him affirming certain local claims without clear criteria, especially when those claims conflict or reproduce harm. By challenging foreign authority without articulating how legitimacy should be assessed within local contexts, he risks substituting one opaque hierarchy for another. The absence of a mechanism for epistemic accountability within the ‘proximate’ space undermines the critical edge of his argument.

Second, the book is epistemically incomplete. It assumes that valuable local knowledge lies waiting to be recognised if only the foreign gaze would look away. While Abimbola acknowledges that local experts often tailor their work for foreign audiences, he avoids more profound questions about how this orientation emerged and why it endures. He does not examine how colonial and missionary legacies have shaped the epistemic cultures of southern institutions, or why local scholars rarely seek to theorise indigenous practices on their own terms. For instance, he praises group antenatal care in Nigeria as a locally grounded example, but never considers how inherited pedagogies already structure such practices. The deeper question is, why has so much southern knowledge production become mimicry rather than innovation?—remains largely unexplored.

This omission is particularly striking in light of historical examples like the suppression of variolation in colonial India. Indigenous practitioners had developed a functional method of smallpox inoculation, yet this knowledge was not allowed to evolve because colonial authorities replaced it with vaccination. The British enforced an epistemic closure from the outside, but the long-term effect was an internalised deference to another’s science. Abimbola touches none of this. He writes as if the gaze is the primary agent, and the south merely its object, ignoring the centuries of adaptation, aspiration, and abandonment that have shaped southern scientific cultures from within.

Finally, the book is strategically ineffective. It underestimates how profound a shift would be required to build independent knowledge systems in the Global South–to shed centuries of epistemic entanglement with the North. To reorient from the foreign gaze is not a matter of redirecting papers to different journals or holding conferences in other cities. It would require building entire epistemic infrastructures: funding mechanisms, review systems, training institutions, and incentive structures capable of rewarding intellectual independence rather than recognition. Abimbola offers no roadmap for this transformation. Nor does he seriously consider whether the current generation of southern institutions—so deeply entangled with northern agendas—could or would lead such a project. In this sense, the book gestures toward autonomy but remains captive to the very structures it critiques.

The core of the problem is this: The Foreign Gaze critiques the act of being watched, but says little about the desire to be seen. It offers a sharp analysis of how knowledge is distorted by foreign audiences, but not of why southern actors so often turn toward those audiences in the first place. Without that second half, the argument remains morally insufficient and structurally incomplete. Finally, it calls for justice, but offers no confrontation with the habits of thought, aspiration, and institutional design that prevent it.

In privileging proximity and local accountability, Abimbola gestures toward a world where “global health” no longer holds together as a coherent epistemic or institutional project, but he stops short of naming this dissolution or reckoning with its consequences.

The Foreign Gaze opens a critical conversation but does not complete it. If epistemic justice is to mean more than moral appeal, it must reckon with both the gaze from without and the longing to be seen from within. Until then, the project risks becoming, in the end, just another performance in the theatre of Northern validation.

Seye Abimbola (2025). The Foreign Gaze: Essays on Global Health. OpenEdition Books: Marseille.

The Great Trade Experiment

Last month I wrote about The Great Foreign Aid Experiment of the Trump administration. Foreign aid has not been without its critics because it is inefficient, promotes corruption, or is a part of an insidious program of neo-colonialism. The decision, however, by the US Government to put foreign aid “through the wood chipper” sets up a natural experiment to test whether aid save lives—more precisely, whether the sudden removal of aid ends lives. Most people in global health believe that it will result in significant suffering, although some see a silver lining: deaths among the poor and vulnerable will mark the emergence of independent health systems in low-income countries that are more resilient and finally free of external interference.

Not content with one natural experiment at the expense of the global poor, on the 2^nd of April 2025, Donald Trump announced the imposition of the highest rate of tariffs on US imports in almost 100 years. In effect, the government is dismantling the free-trade mechanism that has been operating since the mid-1990s, and adopting a more isolationist market posture. Under this new theory of trade, wealth is not created, it is finite and accrued by one country to dominate another.

The evidence has been pretty clear about the effects of poverty on health. Poor people are more likely to die than rich ones. Infant, child, and maternal mortality rates are significantly higher among the poor. Preventable and treatable diseases such as HIV, tuberculosis, and malaria also disproportionately infect and kill the poor. These poverty effects occur both within and between countries. Furthermore, they are not just biological outcomes—they are deeply social, economic, and political in nature. The conditions of poverty limit access to healthcare, nutrition, education, and safe living environments.

Over the last 75 years, in parallel with increasing life expectancy across the globe, wealth has also increased. The proportion of people living in extreme poverty today is much lower than it was 50, 20, or even 10 years ago. In fact, historically the sharpest global decline in extreme poverty occurred between 1995 and 2019—2020 was, of course the COVID pandemic, which reversed a wide rage of health and economic indicators.

Bill Clinton assumed the presidency of the United States in January 1993. He was supportive of free trade and the Uruguay Round of of the General Agreement on Tariffs and Trade (GATT), which was completed in 1994. The successful conclusion of GATT led to the creation of the World Trade Organization (WTO) in January 1995.

Following the liberalisation of trade, global extreme poverty rates fell from 36% to 10% between 1995 and 2018. In South and South-East Asia the extreme poverty rates fell from 41% to 10%. In Sub-Saharan Africa, the extreme poverty rates fell substantially, but without the same speed or depth as elsewhere: 60% to 37%. The gains of trade liberalisation were also more advantageous to some markets than others, and it particularly benefited countries with cheap manufacturing capacity such as Bangladesh and Cambodia.

The sudden US reversal on tariffs will be punishing for those poor countries that have developed a manufacturing sector—particularly in shoes and garments—to provide cheap, volume goods based on low labour costs. Of course, the goods in the US need not be cheap, because there is considerable profit in branding.

If exports drop significantly, factories will want to cut staff numbers swiftly to retain their commercial viability. Poor households, particularly those reliant on a single income manufacturing jobs, will likely be thrown backwards into extreme poverty. The global economic gains of the last 30 years could begin to reverse. A major drop in exports will have an immediate impact on the factories’ labour force but there will be flow on effects to the entire economy of poor countries. In Bangladesh, for example, garment manufacturing is the single biggest source of export revenue, and reductions here will mean reductions in national tax revenue which supports health, education and welfare services.

In other LMICs that are less reliant on a global export market, shifts in tariffs will have a concomitantly smaller impact. Thus, the two natural experiments will intersect. The impact of foreign aid on health and the impact of foreign trade on health will play out with interacting effects.

Needless to say, none of this was ever framed as an experiment. Cutting aid and raising tariffs was all to “Make America Great Again”. It is a cruel, indifferent approach to trade and foreign policy. There will be no one in the Situation Room plotting a Kaplan-Meier survival curve. No policymaker will announce that the hypothesis has been confirmed/rejected: that wealth, when withdrawn or walled off, leaves people dead. Nonetheless, the data will tell its own story.

And when it does, it won’t speak in dollars or trade deficits. It will speak in the numbers of anaemic mothers, closed clinics, empty pharmacies, and missed meals. It will speak in children pulled from school to help at home. It will speak in lives shortened not by biology, but by policy

The Great Trade Experiment, like the Great Aid Experiment, won’t just test theories in global health and economics. It will test people—millions of them. And the results, while statistically significant, will not be ethically neutral. Some experiments happen by accident. Others, by design.

This one was designed—by the President of the United States.

Parasitising Human Rights

A snail glides slowly from the shelter of the underbrush into the sunlight. One of its eye stalks (ommataphore) pulses with an unnatural rhythm, swollen, brightly coloured and weirdly attractive. A thrush spots the movement and swoops down, drawn to the flickering lure, pecks off the stalks and flies away.

The thrush was fooled. What it mistook for a juicy caterpillar was a parasite seeking a new host. The parasite, Leucochloridium paradoxum, is a trematode that infects a snail and turns it into a self-destructive zombie. The life cycle is simple: bird eats parasitised snail, parasite reproduces in bird’s gut, bird defecates, snail eats infected droppings. Once the parasite has been eaten by the snail, it hijacks the snail’s behaviour. It migrates to the snail’s eye stalks and drives it out of the safety of the underbrush and into the sunlight, where it will lure a bird to eat it. Rinse and repeat.

It was only very recently that I realised that the Christian far-right groups had adopted an analogous strategy to attack the international human rights framework and women’s rights in particular.

The Geneva Consensus Declaration (GCD) and its companion, the Women’s Optimal Health Framework (WOHF), function with unnerving similarity to the apparently tasty snail. They are each packaged in the shiny and appealing language of “optimal health”, “human dignity”, and “family”. They infiltrate the human rights system—not to strengthen it, but to hijack it, disguising regressive aims as a legitimate rights discourse. Once absorbed by a State-host, the State is zombified to re-present the regressive framework in shiny, deceptively appealing language waiting to parasitise the next State.

The GCD was first presented to the United Nations as a letter under Donald Trump’s 45^th Presidency of the United States. It was an initiative of the Secretary of State, Mike Pompeo, a fundamentalist Christian. Borrowing the name of the City of Geneva, made famous by its association with refugees, human rights and the Geneva Conventions, the GCD is neither supported nor endorsed by Switzerland nor the the Republic and Canton of Geneva, nor is it adopted by the UN.

The GCD document opens with lofty and appealing commitments to universal human rights and gender equality—pulling deceptively and disingenuously on the Universal Declaration of Human Rights. It declares that “all are equal before the law” and that the “human rights of women are an inalienable, integral, and indivisible part of all human rights and fundamental freedoms”.

Once consumed, there is a parasitic turn. The GCD reverts to a framework that reduces women to vessels and vassals in service to cells and states. The foetus is elevated. It is endowed with rights that eclipse those of the woman herself. She becomes a fleshy bag—nutrients in, baby out—stripped of the autonomy to define her own purpose or direction. The role of the State shifts. It is no longer the guarantor of individual freedom but the authority that dictates what a woman may or may not be allowed to do. “The family”—a surprisingly labile cultural concept—is suddenly reified, declared “the fundamental group unit of society,” as if its meaning were fixed and universal. The document commits fully to a vision of a society where the population serves the State, and women serve the population—with the least autonomy.

Health is a human right as is the right to healthcare. The GCD and the WOHF want to parse this, playing a game of reductio ad absurdum. You might have a right to healthcare, they argue, but you do not have a right to an abortion. As if it makes sense to say you have a right to healthcare, but not if you have scabies, rabies, HIV, or malaria. Pregnancy is not a disease, but it does require healthcare and that care may include the termination of the pregnancy. A woman’s purpose is not reproduction—servitude to a foetus.

Men, too, are caught in the parasitic zombification. They should not mistake their apparent elevation in these structures for freedom. They lose something fundamental. Choice. Authoritarian gender orders assign roles to everyone. Power is not granted—it is rationed and always conditional. The State grants status for obedience and identity in exchange for submission. Those assigned dominance are especially bound by its terms. This constraint brooks no dissent. In a society of freedom, you can find your own place. In a society of roles, your place determines you.

These zombified States do not act alone. The US-backed Institute for Women’s Health promotes the destruction of women’s rights, replacing evidence with sleek visuals and rhetorically based policy tools. The materials are presented as neutral frameworks but embed deeply conservative ideologies—valorising motherhood, framing women’s worth through familial roles, and avoiding any substantive discussion of sexual rights.

States that adopt these frameworks serve as megaphones, amplifying anti-abortion and anti-diversity policies in UN negotiations and global fora. This is not a grassroots movement for gender justice. It is a top-down project of moral, political, and social control, disguised as health policy.

The GCD and WOHF are not neutral initiatives. They are a parasitic ideological vehicle that masquerades as progressive while advancing regressive policies. Their true function is to infiltrate human rights systems, hijack the language of empowerment, and turn States into agents of restriction.

We must name this strategy for what it is: a parasitic ideology—designed to deceive, manipulate, and replicate. Human rights advocates must remain alert, resist co-option, and expose these frameworks not just for their content, but for the insidious strategies they deploy.

The only antidote to such parasitism is clarity, resistance, and the refusal to surrender universal human rights to the State.

Local causation and implementation science

If you want to move a successful intervention from here (where it was first identified) to there (a plurality of new settings), spend your time understanding the context of the intervention. Understand the context of success. Implementation Science—the science of moving successful interventions from here to there—assumes a real (in the world effect) that can be generalised to new settings. In our latest (open access) article, recently published in Social Science and Medicine, we re-imagine that presumption.

As researchers and development specialists, we are taught to focus on causes as singular things: A causes B. Intervention A reduces infant mortality (B1), increases crop yields (B2), keeps girls in school longer (B3), or…. When we discover the new intervention that will improve the lives of the many, we naturally get excited. We want to implement it everywhere. And yet, the new intervention so often fails in new settings. It isn’t as effective as advertised and/or it’s more expensive. The intervention simply does not scale-up and potentially results in harm. Effort and resources are diverted from those things that already work better there to implement the new intervention, which showed so much promise in the original setting, here.

The intervention does not fail in new settings because the cause-effect never existed. It fails in new settings because causes are local. The effect that was observed here was not caused by A alone. The intervention was not a singular cause. A causes B within a context that allows the relationship between cause and effect to be manifest. The original research in which A was identified had social, economic, cultural, political, environmental, and physical properties. Some of those properties are required for the realisation of the cause-effect. This means that generalisation is really about re-engineeering context. We need to make sure the target settings have the the right contextual factors in place for the intervention to work. We are re-creating local contexts. The implementation problem is one of understanding the re-engineering that is required.