Race & Health: Epistemic injustice

Whose knowledge is represented in our health research, policies, and practice? Who is heard, listened to and believed in our health system, and why? There are differences in not only whose perspectives are represented in society, but also what knowledge is valuable. On this episode of the Race & Health Podcast in collaboration with The Lancet Voice, we explore the concept of epistemic injustice: the idea that knowledge and systems of knowledge production favour the perspectives of those at the top of the social hierarchy. We will explore how epistemic injustice works, what this means for representation in research, services, and policies, and ultimately, how this relates to racism and health.

This episode's guests include Dr Seye Abimbola, Associate Professor and Principle Research Fellow at the University of Sydney, Dr Rageshri Dhairyawan, Consultant in Sexual Health and HIV Medicine at Barts Health NHS Trust and an Honorary Senior Lecturer at Queen Mary University of London, and Dr Naidu Thirusha, Head of Clinical Psychology at King Dinuzulu Hospital and an Associate Professor in the School of Nursing and Public Health at University of KwaZulu-Natal.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Delan: Hi everyone, welcome to the third series of the Race and Health podcast. We're partnering with the Lancet Voice podcast to discuss issues related to the recent Lancet series on racism, xenophobia, discrimination, and health, published in December 2022. My name's Dilan Davidkumar. I'm a professor of global child health in University College, London, and was the lead on the academic series.

Today's episode is on epistemic injustice, which we touched on in the first paper. How do we know what we know, whose voice is heard and whose isn't, and what are the implications of this? Who gets to decide? These are the kinds of questions that I'll be talking about with my three guests today. We have Dr.

Tarusha Naidoo, who is an associate professor at the University of KwaZulu Natal and a clinical psychologist practicing in public health in South Africa. Her research focuses on equity in global medical education and global health, inspired by her experiences as a Global South researcher in global health, mental health, and infectious diseases.

Tarisha is interested in how research, authorship, and scholarship practice shape dominant and marginalized narratives. Next is Dr. Rageshree Dharawan, who is a sexual health and HIV doctor and researcher based at Bart's Health NHS Trust and Queen Mary University of London. Her clinical practice, research, and advocacy focus on inequalities, particularly at the intersection of gender and race or ethnicity.

She's an inaugural Wellcome Collection and Spread the Word awardee. She's writing a book on how people go unheard in healthcare, and what can be done to address this. And finally, we have Dr. Shea Abimbola, who's a health systems researcher from Nigeria, who's currently based at the University of Sydney, where he's an associate professor and principal research fellow.

His teaching and research is on knowledge practices in global health. Health System Governance and the Adoption and Scale Up of Health System Innovation. Shea was awarded the Prince Claus Chair in Equity and Development at Utrecht University and is also the Editor in Chief of BMJ Global Health. Thank you all for joining me.

Traditionally minoritized groups have been excluded from research and knowledge production and this has led to some of the racial inequities where we don't know what the issues are and the potential solutions to those issues and this idea of epistemic injustice. Rakesh Shree, can I come to you first?

Can you tell us what epistemic injustice is and why it's important? So 

Rageshri: epistemic injustice as a term was first coined by the British philosopher Miranda Fricker back in 2007 in her book Epistemic Injustice, Power and Ethics of Knowing. And she basically described this as a wrong occurring to someone in their capacity as a knower.

So being able to produce knowledge and to pass it on to each other is a basic human ability and if you can't do that for various reasons, you experience an injustice and we find ourselves losing a bit of our humanity, so it really strikes deep into heart of what makes us human. And she said that this is really a type of injustice that sits alongside other forms of social injustice, so minoritized groups who may face other forms of social injustice often.

experience epistemic injustice. And she came up with two different types, although that has now been expanded by other philosophers to include other concepts. But I can briefly talk you through the main two that she described. So the first one is testimonial injustice. which occurs when a person's voice or knowledge is discounted or dismissed due to prejudice from the listener about their social identity.

So essentially a speaker is seen as not being credible when they speak, they experience a credibility deficit or an excess, potentially, due to stereotypes about their social identity. So it's often associated with the speaker's gender, ethnicity, class, sexual orientation, ability, or religion. And an example that she gives in the book is about a woman going to the police to report that she's been sexually assaulted, but the police not believing her because they don't think that she is a credible witness.

They don't believe her testimony. The other form that she describes is hermeneutical injustice, which occurs when the experiences of marginalized individuals or groups are not understood by themselves or by others. Because those experiences do not fit any concepts known to them or others. And again in her book, if we think about sexual violence again, she gives the example of the concept of sexual harassment in the workplace.

So this was discussed a lot in the 60s and 70s, but before then it wasn't really discussed as a term. So women who were experiencing it perhaps couldn't describe it to themselves, identify themselves as experiencing it and then communicate that to others. So for me, I think epistemic injustice is really important because it can decide who is heard and listened to, who's believed, and also then who is silenced.

So I think it has lots of implications for healthcare. 

Delan: Thank you. Shea, if I could come to you I know you've written on this topic and this, these ideas, testimonial and hermeneutical, and I think in your paper you describe it as interpretive. Can you talk about this framework and your thoughts on this place?

Seye: Yes, thank you very much. I swapped the term interpretive because it's just more intuitive and it's more in prose as it were compared to hermeneutical. And in part because part of what I think of as epistemic injustice is the inability of people to actually share common concepts that they could.

Then share the experience with. So the example of sexual harassment becomes really important here that it was the framing, the language, the term that allows people to communicate, understand themselves and be understood. So for me it's important that one actually uses. language. But for me, the broader framing one of the things that I took seriously is a certain sense in which Frica's framing is almost too individual.

There's a sense in which it is injustice between people and that is important. But in many instances, in many ways, the injustice is also kicked in into the institutions that govern us. And the platforms we use. So we were talking about communication just now, that there are platforms for communication that exclude people.

That even if you were, you don't find yourself on the platform in the first place. And when you do, you are perhaps less believed. So there's something institutional about this injustice that I think deserves a lot. The third qualification that I would give that framework is also that identify two ways in which it manifests.

So the credibility that needs to be tested when an injustice I think of that in time. Grand residency because of one's positionality. But I also think of it perhaps also in addition in terms of one's role as the audience of knowledge that is produced. So for example, when we think about whom do we defer to in how we articulate the knowledge, whose existing knowledge we are taking into account, whose learning needs we address ourselves to, whose preferences in society we align ourselves to, that too for me is a form of that kind of injustice in that who is the worthy audience.

So in addition to the one's positionality as it were. It's also one's role as being the receiver of the knowledge and again, in my mind, I'm always trying to make sure that I give enough attention to that role as audience. Again, knowledge platforms come into being, becomes really important here.

So for example, if I do a piece of research and I only publish it in a particular place, I am implicitly saying that only those who can get to that place are the people worthy. 

Delan: Thank you. So this idea of, I, I guess it mirrors kinda racial hierarchies that exist and there's hierarchies in kinds of knowledge and places that is published in audiences that are, it's accessible to and Trisha, we would like to expand on 

Naidu: this.

Yeah, I think it's an, a good jumping off point to start where Shea left off, which is to say that. Fricker's work is really valuable, but it's quite Western in its orientation in the sense that it implies, especially on the hermeneutical level, it implies a wider social context, but doesn't unpack that explicitly.

It also doesn't unpack a historical context in terms of global dynamics around how people interact around race and the geopolitics of race and how it has been influenced. By global history and what we're living with today. So I would want to extend the idea of epistemic injustice two steps historically backward to look at systemic injustices and structural injustices at the sort of recent past level from the Black Lives Matter and what we'd be talking about there.

But also to go further back to what the decolonial scholars and critical scholars talk about when they talk about knowledge production as it's been happening and how those structures of knowledge and epistemology have been built over generations so that we unconsciously talk, think, write, and build knowledge in ways that re present, replicate, and recreate those epistemic systems.

That are the platforms, that provide the platforms, that are the audiences. So even us that are fighting against it, inadvertently fall into being audience and speaker. So I would want to look back. There's a great paper by Emily Besson in in BMJ Global Health around epistemic injustice and her work takes it one step further and looking at coloniality of knowledge and knowledge production, which is the background story.

of hermeneutic injustice, and we're inadvertently colluding with it, even those of us that push back against it. And of the structural systemic knowledge, but also really become aware of the historical antecedents that created that hermeneutical system. 

Delan: Thank you to all of you. So can I just push a little bit further on what kinds of knowledge are being excluded?

What kinds of data are being excluded and who exactly is being excluded from these conversations? 

Naidu: I could say something about that because I had a conversation based on some research that I'm currently doing and it's research on women's health issues in a neighboring African country. And it's interesting when there is cross national or global health research, how people come in from a different context with different epistemic frameworks and asked the wrong kinds of questions because they want to set up for the kind of data that they're collecting, but they don't have the frameworks to listen for the kind of data that people want to give and that are relevant.

So your question around What types of knowledge and who is being excluded are one and the same thing, because how we speak, our experience in the world, is directly related and inextricable from who we are, which is why positionality and the whole move towards positionality in research is being foregrounded.

For instance, I'll answer by telling you about some of the work that I'm trying to do with the research that I'm doing with women and health issues. And trying to flip the audience, flip the narrative, flip the method on allowing people or encouraging people to give data or to offer data in completely different ways.

So if people need to present their experience through songs, through poetry, entering a space and structuring an interview or collecting data in ways that make sense to us. We let go of our need to, as researchers or people from positions of power, colonized people to control the space and elicit the kind of data we want to elicit.

Seye: Can I jump in there? That if you read the pages of the Lancet, you would hardly see any research paper that is a qualitative research paper. They don't publish it because they've assumed for some reason that it is inferior or that, someone doesn't think it is inferior, someone in the audience.

Doesn't think it's this. worthy, credible. And a lot of the knowledges that you get from struggle and from people on the margin present themselves in that particular way, such that by that singular decision of an elite journal, we exclude the voices of many people whom the journal would otherwise claim it's trying to serve.

I'm going to do the flip side of that, that a lot of the research papers will be papers that are randomized controlled trials, which make a lot of sense for clinical questions about simple direct interventions and make much less sense, perhaps even completely epistemically wrong and unjust.

for more complex things, about which the people you are interacting with, the people you are intervening upon, who's, et cetera, that you are working with, will know far more than to reduce a question to something that can be answered in that basic yes or no way. And very often, we gravitate towards those kinds of methods, in part because journalists love the kind of answers that they present, but also in part because the audience of the research that we do, it's not those people, it's some other people elsewhere.

Who wants to imagine the world as far more simple than it really is. And again, by doing that, we exclude the knowledge of many people, primarily the people of the margins, because those people who we're trying to serve as audience would tend to be powerful, privileged people at the center. So there are different ways in which knowledge platforms work that by definition.

Rageshri: And can I just come in there? So I think particularly clinicians, we really like certainty and a lot of, randomized control trials can sometimes give us that evidence that we can come up with more certain answers. And that is obviously important in things like evidence based medicine, which has been the main paradigm for kind of the last 30 years in terms of medicine.

And, as Shay, Shay said, obviously RCTs are great for some questions, but not good for other questions. And sometimes we just don't have the evidence to be able to answer what we should do with the patient in front of us. And we don't like that, which is why other forms of research and knowledge are so important.

I also just wanted to say just in terms of things like journals, I'm guessing, language is an issue. Most journals publish in English, for example, which may exclude some researchers and other forms of knowledge. And also, I guess the question around fees. So if you want your paper to be open access, you have to pay a very large fee, which also can exclude researchers who may not be able to have the funds to do that.

Delan: And I suppose this goes a bit broader in that science generally is in English. That's changing with the rise of countries like China, for example. But it's broader than just publishing or just journals. Okay, so can we talk a little more about the health impact of epistemic injustice? 

Rageshri: So I think it has a lot of impacts on health in terms about the individual level and at the kind of more group systemic level as well.

So if we take it right down to the consultation room, you've got the clinician and the patient, and we know that patients can often experience testimonial injustice, so they will tell their doctors what are going on. And their doctors may not feel that what they're saying is credible, so they may dismiss what they're saying.

And I think a really good example of that when we talk about a specific condition is endometriosis. So the average time to diagnosis of this condition, which is a very common menstrual condition around the world, is that it takes about eight years to diagnosis. And the reason for that is that people will often say they go to their doctors and they say, we have these very painful.

periods and other symptoms and their doctors don't believe them. They say, this is very normal. Perhaps these symptoms in your head, they may feel a bit gaslit. By the way, they feel rejected by their doctors. So they go back and forth and their diagnosis is delayed. And these kind of repeated incidences can put people off from going to their doctor.

They may not trust that they will carry out what, the investigations they need that can really lead to mistrust as well. So when. Doctors are skeptical of their patient's testimony. It means that patients won't go back to them. So that kind of really individual level can lead to late diagnosis and health impacts.

And also important to think that epistemic injustice can affect patients because they are ill. So there are some philosophers who talk about how just having a long term illness in itself. can put you at risk of testimonial injustice and epistemic injustice because you're not seen as being very capable.

You're seen as being biased because you are ill and you can't be objective. So when we think about things like endometriosis, it's often women of colour who'll say that they've been dismissed by their doctors. And more on a group level, it means that patients can't advocate for the condition they have.

So we may see these conditions being less researched, less funding, being put into policy, less attention essentially. And this can lead to gaps in our collective scientific knowledge. So thinking particularly about women's health, for example, there are considerable gaps. If again, if we take endometriosis, this is a condition that affects one in 10 people who menstruate around the world.

We don't know what causes it. We don't really have any good treatments for it. So perhaps the fact that women over the years have been dismissed means there's been a lack of research, a lack of priority put into that. And when we think the research gender gap, we know that in the UK, a third of women experience a reproductive or gynecological problem in their lifetime, but less than 2.

5 percent of public funds are available to research this field. So I think epistemic injustice has impact specifically for the patient with their doctor, it causes silencing, but also for patient groups and whole disease areas. 

Seye: So in the space of public policy or health policy, something that I.

Spent all my time thinking about is how we decide on the interventions that we decide upon, say a government or a multilateral agency like the World Bank decides that, for example, a country needed X intervention. And I give an example that that I think about a lot is something called performance based financing.

And there was UK with Quality Outcomes Framework, but this is this was a bigger level. And especially in low and middle income countries with weak primary health care system, where the World Bank decides that what needed to be done to improve the quality of primary health care was to give performance incentive to help primary health care facilities, which on the surface of it would seem to make sense.

But if they spoke to people who work in those primary health care facilities, perhaps the first thing they would hear is that the facilities don't have supplies in the first place, or the facilities don't have. They're not being paid their salary, or the road that leads to the facility just doesn't work enough for people to go there.

So there are the ways in which we make assumptions, especially we meaning people who are more powerful, when we decide what people who are much less powerful mean, without actually asking them. And without the willingness to listen and take on board what it is they have to say, because sometimes they actually go and ask and pretend as if we haven't heard what was said to us.

So there's just that example where public policies just fail to achieve their intended purpose because The people who are supposed to be the recipients of those efforts, their knowledge has been discounted, their interpretation of their own reality. So there's just that simple, almost utilitarian argument as to, if you have been epistemically unjust in public policy, you're actually not going to achieve the goals that you've set out to achieve.

But for me, there's another example. I was speaking to a civic official and I said, I asked him why. RNC government funding primary health care and investing in universal health coverage. And he said to me that it's not good to ask people they don't say they want primary health care or universal health coverage.

They say they want good road networks. They say they want water supply. They say they want education for their children. Things that to my own ears sound like at the very heart of primary health care. This is primary health care they are telling you they want. There isn't. Commonly shared frameworks for interpreting priorities between a powerful government figure and people in the community.

Delan: Thank you. So that, in those two examples, you describe, a rich country institution implementing interventions in low, middle income countries, but then also that dynamic within a country where powerful institutions within a country are not listening to the, urban and rural communities in those countries.

Thank you. 

Naidu: Shea and Rakeshri's both ends of the story make me think of the middle. I work in mental health in a very big public hospital in Durban, South Africa. It's a, the most poverty stricken province in my country. And I see both ends, but in a bizarre middle, middle phenomenon that happens where patients don't have a testimonial injustice benefit because the system doesn't hear them.

But then. Even more so because they have mental illness, which is another stigma. There's also the public health level where patients are not heard and share a side of the story. But there's a bizarre phenomenon where health professionals internalize the hermeneutics of the dominant system and try to hear what they should be hearing rather than what patients are telling them.

I'm blabbergasted at how clinicians will keep on asking the questions. But they've learned how to ask and that fit into the system, hoping that if they ask it in different ways, or if they do it differently, the patient will tell them what they want to hear, rather than what is really going on. And this actually is an injustice against the clinician as well.

Being a women of color clinician in a low and middle income country, no one wants to hear your point of view and say, I know this patient, they're my neighbor, I can hear them. But it doesn't fit into the hermeneutic system of language production, of structure, way in which the middle 

Rageshri: clinicians are replicating the system.

Minoritized clinicians will often find themselves not being heard, as you say, in your example. And I think that can really put them off from speaking up more, so they may feel, underconfident, less able to apply for leadership positions, less likely to be on kind of decision making boards. And something that I've thought about for a long time is, this concept of imposter phenomenon, which everyone is now critiquing as they should do, because it is not the problem of the individual person.

It is a societal problem, how they treat people. So if you repeatedly experience testimony injustice, for example, if you're not listened to, you may not think that you are a very good speaker. It might affect your confidence in your career down the line. So I think when minoritized clinicians are not heard again, they can't advocate for their minoritized patients who may be from their community.

I think that's 

Naidu: true in the global North and probably in countries like the UK and the US. where people of color are minoritized clinicians. That's not the case where I am. I'm not a minoritized clinician. Practically everybody looks like me. Everyone would be hard pressed to find the white clinician in my hospital.

But the phenomenon that I'm talking about is that we and my colleagues might internalize the voice of that epistemic injustice and speak and manage the environment as if We have the metaphorical, mythical white clinician on our shoulder and trying to replicate that imposter syndrome is even more besizing than what you're suggesting, where there's an external body and an external system imposing it on you.

Delan: So thank you. And I want to push the conversation forward to look at what we should do going forward. 

Naidu: I want to reflect on what Shelly said earlier, and he specifically mentioned literature, and I think we really, around epistemic injustice, we have to look outside our frames of comfort when it comes to where we seek new ways Of constructing knowledge and how we seek it.

And I'll talk about my personal experience growing up in South Africa and the experience of how you learn what an audience is, how to think about what legitimate knowledge is. It was all Colombian literature. And until I read Toni Morrison's Bluest Eye, and the whole book is about how you unlock somebody because you don't look a certain way that you don't exist as a person because your eyes are not.

It's a very powerful. Book and the work of people like Alice Walker to hear a woman of color, speak a story that I could identify with is a very powerful way of looking at it. And my point is that we need to look outside of academic literature. I've been tracking authors that are our clinicians. And when we write in a creative nonfiction way, and we speak our experiential truth, even if you're not a clinician.

I'm thinking of t. W. Remba's work, which from the moment I read it, Nervous Conditions, really stuck with me and spoke to me. So we have to encourage people to go to literature, to go to other forms of expression, because they connect. Our liminal experience of the world with our conscious cognitive experience and displace us into a different way of experiencing knowledge 

Rageshri: and knowledge production.

That's really fascinating. And I just, I was just thinking what you were saying about the spoils bit and that we haven't really talked much about people who've got credibility excess. So people who are just seen as being. more trustworthy or knowledgeable than they really are. And again, at an individual level in healthcare, that can cause harm because these are the people who will always be bullied by their doctors, they'll get unnecessary tests.

Actually, all they may need is a bit of reassurance, but they may get, unnecessary tests, which may cause them harm. But also when we think in terms of the research space, who gets the funding to do research, they may not be the right people. They will get the funding and perhaps the publications.

I just wanted to. talk a little bit about epistemic injustice and kind of clinical care. I think the training thing is really important. I think in medical curriculums, we are trained to not listen for lots of reasons. So we are inherently taught to be skeptical of our patients testimonies. And that comes out in our language when we talk about patient complains, patient denies, patient alleges, this is routine in patient notes.

The bit about Art is really important. And there is an increasing movement to include more medical humanities and narrative medicine, or we think about medicine more as an art than a science and how we need to have both to really understand the world and be more humble. when it comes to, when we think about medicine and patient care.

And I think a lot of our training really looks at how clinicians see themselves. I think often we can see ourselves as being fixers. We can diagnose a patient, we can fix them, we can use evidence based medicine to make those decisions. But actually a lot of what patients want is just to be heard and listened to and have their suffering validated.

And even if we can't fix them, we need to acknowledge that actually part of our role is to be a witness and to validate their suffering. So I think that's something that's not really brought into medical education. And of course we need listening environments. We need a government that listens, that will fund healthcare.

We need hospitals and healthcare centers where we have the privacy and the time to really hear our patients. 

Seye: So I'm currently doing a paper, a study, which is quite a big review. I'm trying to synthesize a lot of the discussion that has gone on the last sort of five, six years in global health literature around epistemology, around the knowledge practices of global health.

And in doing that synthesis, which is a very difficult synthesis to do because it's all over the place. It's huge. I had to distill the conditions that actually lead to a lot of epistemic injustice down to six. So the first one is the mislabeling of people as individuals, as well as group or mislabeling, mislabeling of issues, right?

So this idea of imposter syndrome or race as an explanation for health outcomes, or in fact, some countries as low or middle income countries, or some people as vulnerable. Think of vulnerable, you can flip it to vulnerabilized, for example, or minority as minoritized. And again, the weight of just flipping the language you use, how that we label phenomena can reshape how we think about them in ways that allow us to see the world better and see people more clearly.

The second category is What I call mis education, but it's, again, it's in many ways that a lot of the things we do, we've been educated to do, went to school to be taught how to be epistemically unjust in many ways, and we just carry on. And it's important that we go back and begin to try and see if we can address that.

The third one is under representation, which is much talked about. So it's the idea that the fewer of a certain kind of people you have in a space, the more likely it is that their views are is represented in those spaces or not represented at all. The fourth one is under governance. In other words, there's this sense in which, linked to education, but slightly different, which is the idea that we exist in epistemic spaces without rules to govern us for the most part.

So that we default to the, how the machine rules and we just run with it. And the need to begin to think about how we craft rules that constrain us. to justice. The fifth one is tentatively called compounded spoils, which goes back to the idea that those who have more. So you've stolen wealth.

The English colonized the world. And so the whole scientific establishment is now in English and it continues to be that also means that those who were taken from. Continue to lose. So the more you want, once for compounds, the more ones, the other sides loss compounds. And again, we get to think about how to address that in different ways becomes important.

The final one is, and again, going back to the space of art there's a song by the Nigerian Afrobeat artist Fela Kuti which is called Kolo Mentality. And there's a line in it where it is. Cologne mentality. They don't release you, but you never release yourself. So that's in Pidgin in English now, which is they have released you, but you haven't released yourself.

And he was talking about the post colonial condition in Nigeria. There were too many Nigerians who were singing in the sixties and seventies, but too many Nigerians who still want to be British and that you need to free yourself from that. And that's the final point here, that there's a sense in which.

One gets conditioned by one's colonizer or in different setups where you want to be like them instead of actually reclaiming who one is. So again, that reclamation process, which is tied to Education which is tied to labeling, all of these things are connected in many, in deep ways. If I can, Delanna, I wanted to ask Sirisha to talk a bit more about that, the ways in which existing cultural practices in many colonized settings or around care were destroyed in many ways by the colonial experience, by the imposition of Western medicine has been.

And just thinking about what Ragesh was describing there, that there are other ways. In many different cultures around care that in some places are completely lost and some other places are struggling to, to remain vibrant. 

Naidu: So that's an interesting example. 'cause I can talk about a specific example in psychiatry because that's the environment that I work in and.

When I started my training, as soon as somebody mentioned having gone to a traditional healer for mental health kind of problems, they would just be dismissed. It would be really derogatory words like witchcraft would it be, would be used and clinicians who had been colonized the way I see it would not allow for the person to even talk about the experience in seeing traditional healers and going to their traditional doctors and made and people were made to feel like they were even more mentally ill and their whole system.

was criminalized, if you want to call it that, because even traditional doctors would not be legitimized in this system. More and more, I'm seeing now that when patients appear and present with what might appear to be psychosis, initially, they're often asked, have you seen your traditional doctor?

And because of that openness, clinicians, even senior clinicians, are starting to recognize the difference between mental illness. And then other types of experience. For instance, there is a condition where in Africa, I don't know if it's in other parts of Africa, but in South Africa, where people have what's called a calling to become a traditional doctor.

It's called Mbezo. So they have dreams, they will have hallucination hallucinations, and it can appear very much like a psychotic disorder. Obviously, if you see it, people don't always want to be a traditional healer. So they will. It can be dampened down by a proper by a proper traditional healer.

But as soon as you're presented at a hospital, you get given antipsychotic medication, you get dismissed. But more and more people are starting to recognize how these two presentations are actually different. When someone presents with the calling, with Mbezo, it is quite different from a psychotic disorder.

So the patient testimony is being recognized. They've become more credible only because the system's gaps have opened up. And people in power are now part of the system that frames this as a legitimate experience in the range of human experience. I think my final thought would be probably for clinicians to think about how we've internalized the injustices that we experience and how we replicate it and perpetuate it and inflict it on others.

And the way to extricate ourselves from it. Is to look at other spaces like literature, poetry, art, and to dialogue with people that have these same experiences and people that are completely different from us. So to really be aware of how we, no matter how open minded we think we are, and no matter how benevolent and caring we think we are, we have internalized this colonial system, this punishing kind of system.

ourselves. 

Delan: Thank you. Thank you to all my guests Tarusha, Rakesh, Rijay you've all talked so powerfully about what epistemic injustice is and how it relates to health, but at an individual level through to a structural level, so thank you to all of you.