‘Health’ as a subject matter for knowledge production has predominantly been biomedical. The success of modern biomedicine is largely founded on, 1) an ontological commitment that constructs the patient as an object of inquiry stripped of existential aspects beyond the bio-physio-chemical ones; and 2) a reinforcement of the value of epistemic distance as a scientific virtue. This combination yields a distant and impersonal approach to healthcare. Often driven by big-data technologies and capitalistic incentives, this mode of knowledge production carries a distinctly alienating force. Distancing occurs at least at two levels. First, through abstraction and causal reduction; the patient and their disease is made as distant from their lived context and experience as possible, and second, the physician is at a distance from the patient as a person and their everyday life with its vicissitudes.

As biomedicine continues to prioritise such forms of knowledge, a parallel world of global public health exists, shaped by small, often unseen, grassroots actors whose proximity to the everyday lives of communities holds great potential for public health, healthcare practice and knowledge production. Proximity to the lived context of a patient reveals structural forces shaping health and wellbeing. These upstream determinants of health are realised in the everyday struggles of people with access to what should be common or public goods such as safe drinking water, nutrition, clean air, dignified housing and livelihoods, legal justice and so on, but are instead increasingly commodified. Grassroots organisations, people’s movements, scholars, and activists have brought increasing attention to these in articulation of the health equity discourse that not only gives an immediacy of epistemic access but also puts a pressing moral demand to care and act.

Academic institutions that aim for health equity within resource-limited settings often partner with larger, more established actors, e.g. local or international NGOs, for their proven track records of ‘legitimate activities’, high impact stories, capacity readiness and ability to meet regulatory or donor-driven compliance requirements. This group of actors often then become the dominant (or default) representation of strong partnerships and community engagement, reshaping perceptions of proximity and ‘localisation’. While these larger actors may be valuable in some contexts, such partnerships are not always built on longstanding relationships of trust with the community, and may centre on high-visibility metrics, inadvertently producing extractive research, which is then conducive to reinforcing power imbalances. These features may not always be an inherent feature of larger dominant actors, but it does reflect to a degree, the structural tendencies which shape their engagement and outputs.

Meanwhile, small-scale, grassroots non-profit organisations, that are less bound by organisational imperatives and institutional pressures, who work in close (sometimes closest) proximity to communities, and are fully integrated within community culture and the social fabric, are either sidelined or remain unseen. They exist, but are not looked at, or engaged with, or listened to enough. These unseen actors often emerge through the action and participation of community members in a collective response to their own communities’ needs. They are developed organically, for example in the aftermath of emergencies when demand for support is acute, or to raise the issues of injustices including the state backed, corporate led violation of indigenous people’s lands and resources. Their community embeddedness gives them insight into the lived realities, relational dimensions, and determinants that influence everyday practices. Yet, they are not engaged with (or studied) enough by global public health academic institutions.

Moreover, state-controlled funding restrictions for non-profits in certain contexts further impact any opportunities for visibility. The 2010 law in India for example, and the subsequent amendments to it in 2020, was done to regulate receipt and utilisation of foreign funds, which has made it almost impossible for small-scale entities to function. The laws and law enforcement agencies have been weaponised to target non profit entities voicing legitimate criticism of government policies. The development sector has weakened and small grassroots organisations have been worst affected.

While larger actors may have better backing and far-reaching networks emerging from an often-centralised hub, smaller unseen actors organically develop as multiple decentralised ‘hubs’ within those same networks, harbouring richer, often untapped, knowledge of systems and communities. They stay or return frequently to communities; they become a household name and a familiar and trusted presence. You can find them by talking to community members in the middle of neighbourhoods, slum settlements, and informal gathering spaces where local life unfolds. Community members will tell you who was there for them when the government was not.

Community engagement efforts in partnering with unseen grassroots actors is closer to eliminating abstract interpretations and strengthening the validity of public health inquiry. Such a kind of partnership requires a willingness to understand the intricate mechanisms that shape community health and wellbeing; a feat which cannot be done through parachute research or short-term contracts. It calls for openness to the embodied forms of engagement offered by these actors; peoples and groups who are neither dominant saviours nor holders of capital or white-collared expertise, yet who are the first to respond when systems fail. The route to engaging with this type of grassroots actor would inevitably be unstructured, multifarious, messy and informal. Are academics ready to make this type of engagement a norm? Although the tide is turning, it is slow. In the current climate of populist anti-intellectualism, academia needs to carefully reflect on what counts as a marker of institutional credibility among the wider public. The value of proximity is ever more pertinent for epistemic, moral, and political reasons.

Authors: Dr. Neha Faruqui is a global health academic at the University of Sydney. Her research and practice work predominantly focuses on health systems and community engagement with marginalised groups.

Jatin Sharma is a student and practitioner of philosophy and people’s health. He is co-founder and director of ‘Hausla Health Initiative’, a not-for-profit that works with unsheltered people in Indian cities. Jatin is also a member of ‘Platform People First’, a collective working on social and political determinants of health.

Competing interest: Neha is the blog editor for BMJ Global Health

Handling Editor: Neha Faruqui (editorial blog)