Introduction
We humans, in one way or other, consciously or unconsciously draw from existing epistemic resources. However, the access to and quality of these epistemic resources are shaped by historical patterns of social enterprises (e.g., racism, sexism, and colonization), leading to credibility excess in one epistemic enterprise at the expense of credibility deficit in other epistemic enterprises.1 This situation creates an epistemic void among the marginalized and excluded social groups – creating a multiplex of ‘epistemic indebtedness’ that stretches back to centuries. Epistemic indebtedness can thus be referred to as a state of owing debt and gratitude to the global knowledge reserve (aka knowledge pool) that subsequently engenders a moral obligation to contribute.
Over the years, the declining interest and contribution to science by the population, including the underrepresentation of knowledge and its synthesis in the global south, has been disconcerting.1 Knowledge is a product of investments by research institutions and scholars, yet a large proportion of the population seems to overlook the need for a contribution to science. The neglect of epistemic synthesis is further threatened by the declining trust and disconnect between the public and scientists.2 In this article, we build on previous discourse on the relevance of knowledge production and its investment in the context of low- and middle-income countries (LMICs).1
Epistemic gaps in LMICs
Epistemic gaps are increasingly being appreciated within high- and low-income countries.1 Many factors play a role in why distrust in science often leads to poor contribution to science and ‘epistemic indebtedness’. For instance, the rough history of the medical establishment and unethical research on the black population in the US has built distrust that continues to affect the trust towards science and evidence generation.2
At current, when the public’s interest in science and trust in the scientific enterprise is constantly challenged, it is critical to explore the levers of evidence synthesis and uptake.3 It is obvious that a large proportion of the population may not comprehend the scientific knowledge and language used in its communication. In response to widening gaps between science and the public, public/community engagement activities are increasingly being conducted. Despite the increase in community and public engagement activities, gaps between scientists and the public remain a major challenge.
Current discussions around epistemic injustice in global health are relevant but are an incomplete lens for looking at global epistemic disparities.1,4 Both testimonial and hermeneutical (interpretative) epistemic injustice offer insights into how there have been systematic and structural barriers for LMIC authors to contribute to science and literature, leading to the unfair representation of knowledge and experience in collective social understanding.1,4 Nonetheless, inherently social, cultural, and behavioral elements among the population in LMICs tend to compound the existing barriers.
The utilization of knowledge alone without adequate contribution towards it bears implications. Exchange of knowledge with materials (or money) without replenishing the resources and thoughts on furthering the science and technology can ultimately exhaust the evidence base. With declining interest and trust in science, the likelihood of sustaining science and its product is further threatened.2,5
Investment in knowledge and its base, particularly in expanding the science and its quality, is critical to maintaining the integrity of evidence-based decision-making, including public trust in science.6
Why and how are LMICs indebted to epistemology?
There are both extrinsic and intrinsic factors for LMICs’ growing epistemic indebtedness. One of the prominent examples of how epistemic injustice is perpetuated is the continuous neglect of understanding the local indigenous knowledge and lived experience.7,8 Instead, unquestioningly scholars tend to adopt an existing, pre-meditated framework and theories to investigate the issues that deserve an emic lens, which can undermine the authenticity of knowledge.8
With the difference in access to health care, wealth, and literacy, the population in LMICs tend to perceive inferiority complexities due to the predominance of science and technology which they are unfamiliar with. Deprivations in health care, wealth, and literacy also lead the LMIC population to live a vulnerable life followed by a reticent and modest cultural upbringing. Population in LMICs have socially constructed norms and values that frown upon the attitudes that promote self-grandiosity, self-pomposity, and self-importance. Cultural attributes affect the individual (construct of selfhood), and social behaviour, and thus disease epidemiology.7 Although humility and reticence do have benefits, they have ramifications related to their contributions to epistemic synthesis and sharing.
While the process and outcome of knowledge synthesis can be affected by socio-cultural behaviours such as humility and reticence, the perceived lack of epistemic indebtedness in LMICs may simply emanate from competing priorities. Lack of adequate investment in research and development obliges academics to depend on and submit to the existing epistemic reserves. Pedagogical practices in the Indian sub-continent are still largely didactic that succumb students to be following hierarchical orders and conforming rather than questioning the genesis and application of knowledge. Such a practice may ultimately overlook the research and its output. For instance, in India, only 25 (4.3%) of the institutions produced more than 100 papers a year but their contribution was 40.3% of the country’s total research output.9
As much as we strive to sharpen our skills and expand the knowledge base to improve our living and quality of life, we need to share these skill sets, and epistemic backgrounds with others so that they can be replicable. Replicability is one essential tenet upon which modern science hinges and leaps forward. More broadly, sharing of knowledge, globalizing the scientific prowess, and contributing to a global pool of knowledge are predicated on how an individual is affected by the social, cultural, and academic spheres.
We know a lot less about Asian traditional medicine, its practice, and its impact, compared to well-invested, well-developed western medicine. Traditional medicine and its practitioners are part of the deeper social fabric in Asia and Africa, yet we know little about them and their impacts. This may have emerged from the tendency to maintain the discipline/tradition amongst a specific hierarchy and a circle. Such tendencies seem to be a driver of how the tradition/or the skills are secretively ceded from one generation to another.
One prominent example of how such tradition may have secretively survived without public acquaintance is the use of Artemisinin in treating malaria. Artemisinin known as ‘Qinhaosu’ has been in use for centuries to treat malaria/febrile illnesses in China, but the knowledge about its use and its potential to save hundreds and thousands of lives was only known later in the 1960s.10,11 The persistent neglect of the evidence around Qinghaosu even after its clear evidence was published in Chinese medical journals was deemed with suspicion and was untranslated in policy by WHO. Only in 2006, WHO recommend the use of Artemisinin Combination Therapies (ACTs) without any reservations.12 This demonstrates either a lack of adequate advocacy or a general under-appreciation of evidence published in local journals, which may well have been barred from reaching a global audience due to language barriers.12
Inherent lack of intention to publicize the knowledge and fight off the barriers to globalizing the knowledge and failure to share it as a global commodity does warrant accountability. The redress to a failure to share the epistemic base (epistemic indebtedness) to a global audience thus comes with greater responsibility and below we discuss how such an epistemic indebtedness can be addressed.
Addressing barriers to epistemic systems
Our précis on the epistemic gap may refer to a lack of epistemic globalization, there may be adequate epistemic synthesis but inadequate efforts in the globalization of the knowledge.
Globalizing the epistemic base and sharing what has been systematically overlooked over the years require steps that need a regional priority and advocacy (Figure 1). The general visible trend where scholars from Asia or elsewhere (from the non-English speaking region) tend to have barriers in an individual, social and academic arena, such that the epistemic synthesis is unevenly published in international peer-reviewed journals.1,13 Scholars and stakeholders need to place equal if not less priority on its global dissemination (not just at an individual, social or national level).14
Scholars and researchers in LMICs are caught in a vicious cycle of barriers to access and publishing in international journals that ultimately contribute to a vicious cycle of poor epistemic synthesis and remained a servant to epistemic reserves based in high-income countries.13 Multi-faceted efforts are critical to encourage LMIC authors to stand up to the epistemic contributions. The lack of epistemic contributions from LMICs to the global epistemic pool does not qualify the current global health to be a true ‘global health’.
Conclusions
Reflected in the current epistemic synthesis, over the years and with the gradual process of epistemic imposition, LMIC authors have succumbed to both enacted and perceived inferiority in how they could contribute to global epistemic reserve. Values borne in ethnic culture and practice which are often unrecorded and underappreciated suffer the systemic epistemic injustice. Thus, it may be more discerning for current global health and practice to focus on promoting the realization of the epistemic gap, and indebtedness that should be perceived heavily by LMIC researchers before we conclude our discourse on the ‘why’ and ‘hows’ of epistemic injustice.
Notwithstanding the injustice imposed upon LMIC’s epistemic reserves, few countries (e.g., China, India) have revived (indigenous) epistemic sanctuaries (e.g., places to forge knowledge, e.g., journals, databases, conferences, dialogues). We hope these sanctuaries of knowledge will continue to expand – increasing global reach and to offset the centuries of a credibility deficit. This requires quality and rigour to be baked into LMIC’s budding epistemic enterprise.
To conclude, global health enterprises need to revitalize local epistemic enterprises to undo the historical and existing epistemic injustices imposed on them in various forms by liaising with governmental and non-governmental actors.
Acknowledgments
We are grateful to Prof. Phaik Yeong Cheah, University of Oxford, for her feedback on our initial draft.
Funding
None.
Authors contributions
All authors contributed to the conceptualization, data screening, inclusion and extraction and manuscript drafting. All authors reviewed and approved the final manuscript for publication.
Competing interest
The authors completed the Unified Competing Interest form (available upon request from the corresponding author) and declare no conflicts of interest.
Correspondence
Shiva Raj Mishra, Nepal Development Society, Bharatpur, Chitwan, Nepal and, University of Melbourne of Population and Global Health, Melbourne, Australia; shivaraj.mishra@unimelb.edu.au