Whose knowledge counts? Learning from epistemic injustice in global health

This post, by Michael Bresalier, reports and reflects on a recent, interdisciplinary workshop about epistemic injustice in global health.

Global health aspires to reduce inequality—but its structures can also reproduce the very inequities it seeks to solve. This paradox sat at the heart of a recent EPIC roundtable on Learning from epistemic injustice in global health. Organised and convened by Michael Bresalier, the roundtable brought together a health systems researcher, a legal scholar, a consultant physician in HIV/Sexual Health, a doctoral researcher in mental health, and a philosopher to tackle this paradox. Seye Abimbola, Himani Bhakuni, Rageshri Dhairyawan, Ian James Kidd and Linda Maqutu shared their insights on how knowledge and power shape global health, how these forces determine whose voices are heard and ignored, and ways to address epistemic injustice in healthcare systems.

Defining key terms:  ‘epistemic injustice’ and ‘global health’

To start, panellists were asked to define the two key terms under discussion. They broadly agreed that epistemic injustice involves harms done to people in their capacity as knowers. Kidd explained that people have fundamental “epistemic needs” – to understand, interpret and share knowledge – and injustice occurs when these needs are blocked by prejudice, bias, or structural exclusion. Bhakuni extended this to global health, describing systematic forms of epistemic harm that affect entire populations, particularly through credibility deficits (where local expertise is dismissed) and interpretive marginalisation (where communities lack the resources to define their own experiences). Dhairyawan characterised epistemic injustice as one of the ways in which healthcare can dehumanise individuals and groups. There was broad agreement that these injustices are not incidental but deeply embedded in healthcare systems.

Defining global health proved more difficult. Rather than settling on a single definition, panellists agreed that global health is a set of relationships structured by inequality. Abimbola offered a resonant framing of global health as a “meeting of unequals,” a relationship structured by disparities in power, resources, and authority—especially epistemic power—that shape how health problems are defined and addressed across the globe. This imbalance determines everything from which problems are prioritised to how research is conducted—and whose knowledge is seen as legitimate.

Others reinforced this relational view. Bhakuni stressed that the “global doesn’t exist without the local,” pointing out that similar power asymmetries recur at multiple scales – from international partnerships to doctor-patient interactions. Maqutu similarly pointed to “unequal epistemic authority” not only between the Global North and South but also within healthcare systems. Taken together, global health emerged as both an aspirational project of reducing health inequities and a field structured by persistent asymmetries in what knowledge is produced, valued and applied.

Colonialism and epistemic injustice

A particularly nuanced discussion focused on the relationship between colonialism and epistemic injustice. Panellists agreed that colonial histories are deeply entangled with global health but resisted reducing all epistemic injustice to colonialism alone. Abimbola described the relationship as a “Venn diagram”: overlapping but not identical. Colonialism is one important driver of epistemic injustice, he suggested, but epistemic harms can also arise from other forms of exclusion and hierarchy. At the same time, colonial legacies continue to shape whose knowledge is recognised in global health. Maqutu illustrated this through the marginalisation of Indigenous knowledge systems, such as African traditional medicine, which are often excluded in mental health provision even when they are central to patients’ health beliefs and lives.

The roundtable stressed that while global health remains historically entangled with colonising forms of power, not all epistemic injustice in global health is colonial in origin. Overextending this connection risks collapsing complex problems into a single historical frame. Instead, analyses of unjust knowledge systems in global health require multifactorial perspectives.

These complex dynamics become especially visible in practice. In a discussion of the challenges in justifying funding for a small study of intimate partner violence among HIV-positive women, Dhairyawan described how both patients and healthcare workers can experience dismissal or silencing, sometimes leading to “testimonial smothering.” Abimbola highlighted how global metrics or standards—often set by organisations like the WHO—can distort local realities when imposed without context, forcing countries to “understand themselves” through external frameworks while ignoring local health realities. Across these cases, epistemic injustice appears as a structural feature of how knowledge is produced, validated, and applied.

From inclusion to transformation

When it came to solutions, panellists agreed that responses to epistemic injustice must be context-sensitive, dialogical, and attentive to power. But individual-level changes—such as encouraging clinicians or researchers to listen more—are not enough. While individual virtues such as empathy are important, they are insufficient on their own. Structural change is essential.

Bhakuni proposed reframing epistemic harms as violations of dignity and rights, requiring institutional accountability. Maqutu argued for epistemic decolonisation: not just including marginalised voices but transforming the standards by which knowledge is judged. Abimbola cautioned that even well-meaning efforts at inclusion can fail if underlying power structures remain unchanged.

Kidd added an important caveat for those using the epistemic injustice as a universal framework. Dominant understandings of epistemic injustice often reflect moral and political frameworks rooted in Global North traditions. Scholars in the Global South have challenged this apparent universality, emphasising the need for broader, more context-sensitive interpretations. In this view, epistemic injustice should be understood not as a single fixed concept, but as a wide class of epistemic wrongs—arising from prejudice, bias, and exclusion—shaped by long, complex historical and social processes, including but not limited to colonialism.

The roundtable closed with a powerful insight. Epistemic and material harms are deeply intertwined in healthcare. Ignoring people’s knowledge not only marginalises them—it can also undermine trust, worsen health outcomes, and deepen inequalities.

While global is committed to justice and equality, it often operates through unequal knowledge systems. If it is to live up to its promise of equity, global health must come to terms with this paradox. This means grappling not only with disparities in resources, but with inequalities in knowledge itself—asking, at every level, not just what works, but whose knowledge counts.

Watch the workshop in its entirety here: https://www.youtube.com/watch?v=ITsCjkTwijk

Further reading

Seye Abimbola (2024), The Foreign Gaze: Essays on Global Health (open access), Marseille: IRD Editions.

Himani Bhakuni and Seye Abimbola (2021), “Epistemic injustice in academic global health,” The Lancet: Global Health.

Himani Bhakuni (2023), “Epistemic repair in global health: a human rights approach towards epistemic justice,” BMJ Global Health.

Rageshri Dhairyawan (2024), Unheard: The Medical Practice of Silencing, Trapeze: London.

Linda Maqutu (2025), “Challenging Philosophical Instincts and Embracing Complexity: A Commentary on Elizabeth Barnes’s Health Problems,” Philosophical Psychology.

Author bio

Michael Bresalier is Senior Lecturer in the History of Medicine at Swansea University and Special Investigator on EPIC, for which he leads a case study on the history of ’selective’ tuberculosis vaccination in Britain, 1965-2005.

Epistemic injustice in global antimicrobial resistance research

Today's post comes from Phaik Yeong Cheah at the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand, and Nuffield Department of Medicine, University of Oxford, Oxford, UK. This post summarises her recent co-authored paper "Tracing epistemic injustice in global antimicrobial resistance research".

Introduction

Antimicrobial Resistance (AMR) arises when microorganisms such as bacteria, viruses, fungi, and parasites become resistant to the medicines used to treat them. This makes infections harder or impossible to treat and increases the risk of disease spread, severe illness, and death. AMR affects everyone but disproportionately harms disadvantaged and marginalized populations. Despite this, the experiences, data, and voices of these communities are often excluded or overlooked in AMR research.

Epistemic Injustice and AMR Research 

This paper focuses on epistemic injustice in AMR research—questions such as what causes AMR, who is most affected, what drives AMR, and what can be done to mitigate it. This form of injustice contributes to a lack of representation, skewed priorities, and blind spots in global AMR efforts. We identify three overlapping domains where epistemic injustice occurs and emphasize the need to include diverse perspectives and community voices to make AMR research more inclusive, equitable, and effective. This work is part of a broader project exploring justice in the context of AMR.

Firstly, who sets global AMR research priorities? One key area where epistemic injustice arises in AMR research relates to how global AMR research priorities are set. These priorities are largely determined by the WHO and international funding bodies that support AMR research globally. However, priority-setting exercises rarely include substantive representation from people in low- and middle-income countries (LMICs)—whether they be researchers, clinicians, policymakers, or affected communities.

Secondly, who produces, interprets, and uses AMR knowledge? While AMR disproportionately affects people in LMICs, research in this field is largely dominated by academics from high-income countries and a small number of disciplines. Additionally, researchers from low-resource settings face significant barriers to publishing in high-impact journals. Language challenges hinder their ability to produce competitive manuscripts, and limited access to protected, paid research time constrains their capacity to write. This imbalance perpetuates epistemic injustice in two ways: it limits opportunities for LMIC researchers to shape global AMR knowledge, and it sidelines valuable experiences, knowledge, and potential interventions that could emerge from these settings.

Finally, what knowledge is currently available and valued? A major gap in AMR research is the lack of data from LMICs, particularly in medically underserved areas and communities. This can lead to surveillance strategies that are unrepresentative of the populations they aim to serve. Significant data gaps or biases in AMR prevalence hinder reliable estimates, especially in regions with limited laboratory capacity and data collection systems, potentially resulting in inappropriate responses. There is also a lack of data on health-seeking behaviors, health practices, and medication use in many marginalized or vulnerable communities worldwide.

Consequences of Epistemic Injustice in Global AMR Research 

Epistemic injustices in AMR research create "blind spots". These include a dominant focus on high-income countries, hospital-based interventions, and drug development, while critical LMIC issues—such as infection burden, antibiotic use in livestock, prescribing practices in primary care, and access to affordable diagnostics—are overlooked. These imbalances can also lead to unintended consequences. For example, malaria rapid diagnostic tests have increased antibiotic use in some countries, and AMR awareness campaigns have sometimes instilled fear or unfairly stigmatized small-scale farmers.

Suggestions for the Way Forward 

To address epistemic injustice in global AMR research, we recommend inclusive agenda setting with diverse representation across geography, disciplines, and gender. Research should include under-served populations, removing barriers to participation and recognising their agency. Community engagement around AMR should be encouraged to ensure the voices of affected communities are heard.

Phaik Yeong Cheah is a Professor of Global Health at the University of Oxford. She co-leads a project funded by the British Academy (GCPS2\100009), ‘A Just Transitions Framework for The Equitable and Sustainable Mitigation of Antimicrobial Resistance’ project.