Rame-Montiel et al offer a compelling articulation of how indigenous health professionals envision dismantling racism within medical education and healthcare.1 Their work illuminates the ongoing impacts of anti-indigenous racism, from dehumanisation to deficit-based curricula, and centres Indigenous voices in charting pathways towards justice. Yet, as we read their thoughtful analysis, we found ourselves returning to a fundamental question: Within what institutional conditions might such transformation actually occur? The authors call for challenging dehumanising narratives, incorporating relationality, centring indigenous-led justice and developing skills to address discomfort. These are vital recommendations. But they presuppose something that deserves interrogation—the existence of genuine academic freedom to pursue such work. Diversity, equity and inclusion (DEI) work, precisely the work required to humanise medicine, faces growing legislative and institutional restrictions that directly constrain academic freedom, with faculty self-censoring, educators hesitating to teach content necessary for clinical safety and health equity and researchers facing shrinking funding opportunities.2-4 In the United States, the American Association of University Professors (AAUP) defines academic freedom as the freedom to do academic work, encompassing teaching, research, intramural governance speech and extramural citizenship, which is distinct from individual free speech in that it is tethered to disciplinary competence, peer review and the public mission of universities.5 Further, in health professions, academic freedom is considered valuable but not absolute, that is, it must be weighed against other rights and potential public harms. Academic freedom depends on the speaker's domain of expertise and may differ for intramural expression (internal university governance) and extramural expression (public-facing speech).6 Crucially, these guidelines bind these protections by ‘professionally competent’ inquiry, raising a pivotal question: Who defines competence? When peers determine what counts as rigorous or professional, structural biases infiltrate those very standards, devaluing Indigenous methodologies, community-engaged designs and equity-oriented scholarship, such that academic freedom inadvertently functions as a carefully maintained institutional illusion. Consider the participant in Rame-Montiel's study who described how ‘the moment that it comes to challenging or redistributing power to non-white non-hegemonic places or people, they all suddenly become really close and this could be tangible, like a work crew all of a sudden two white folks become buddies to protect that power’. This observation captures what Derrick Bell termed interest convergence, the principle that advances for marginalised groups occur only when they align with the interests of those in power.7, 8 Envision a scenario of an indigenous faculty member at a public medical school who, while delivering a keynote address at a conference, speaks candidly about how settler-colonial policies continue to shape health disparities and calls for land acknowledgements to be accompanied by material reparations. Government officials, alerted by media coverage, contact the institution questioning whether such political statements represent the medical school's position. Suddenly, the institution faces a choice—defend the faculty member's academic freedom or protect research funding and political relationships. The calculus is rarely in doubt. Administrators may counsel the faculty member to ‘moderate their tone’ or confine such discussions to less visible venues, framing this as protection rather than censorship. Academic freedom, in such moments, reveals itself as contingent upon not disrupting the interests of those who fund and govern institutions. Defining the scope of expertise proves equally problematic when examined through a critical lens. What counts as expertise and credible evidence is saturated with ideological assumptions. When DEI infrastructure is dismantled and equity-oriented scholarship chilled, the conditions are ripe for precisely what Rame-Montiel's participants described: ‘omission, erasure and whitewashing’ in medical education.1 Without structural commitments to inclusion, institutions default to deciding whose knowledge counts as valid, systematically devaluing Indigenous healing practices and dismissing lived experiences as insufficiently objective. The impact falls disproportionately on minoritised faculty, whose scholarly identities and research agendas are most likely to be deemed political, effectively narrowing their academic freedom while leaving dominant epistemologies unquestioned. These acts constitute what philosophers have termed testimonial injustice, the systematic compromising of a speaker's credibility through institutional power structures.9 As Foucault points out, power is not simply repressive; it is productive.10 Institutions do not merely prohibit certain forms of knowledge; they produce regimes of truth that render certain ways of knowing intelligible while excluding others. Academic medicine celebrates evidence-based practice while defining evidence in remarkably narrow ways, predominantly randomised controlled trials conducted in wealthy nations, analysed through frameworks that assume the individual patient rather than structural determinants of health. This is not because such knowledge is inherently superior; it is because institutions have determined which epistemologies receive funding, publication and valorisation.11 Academic freedom, in this context, means freedom to work within predetermined boundaries. The implications for the anti-racist, anti-colonial reforms Rame-Montiel et al envision are significant. Their participants identified that justice requires institutional accountability through transparent policy, transparency in partnering with Indigenous communities, elimination of deficit-based approaches, compliance with indigenous-led directives and meaningful engagement with communities beyond institutional statements. These recommendations are precisely the kind of transformative work that existing power structures are designed to contain. When indigenous health professionals advocate for relationality, described as recognising humanity in each other and understanding how relationships interconnect to shape health, they are calling for nothing less than a fundamental reconceptualisation of medical knowledge production itself. Yet, remaining within the institutional vocabulary of academic freedom, whether defending it or lamenting its erosion, accepts the very terms that produced the problem. What is required is not better protection of a principle that was never meant to be universal, but a fundamentally different conceptual framework for intellectual and social resistance. Here, the work of Moten and Harney offers guidance.12 They argue that meaningful intellectual and social resistance cannot emerge from within formal academic structures precisely because those structures are designed to contain and regulate such work. They propose instead the ‘undercommons’, which is not a physical location, but an attitude and practice of fugitive planning and intellectual work conducted in the margins and shadows of institutions. To be clear, the undercommons is not a catch-all refuge for fringe politics or anti-evidence activism; it is a method of protecting communities and truths that dominant institutions have rendered vulnerable or illegitimate. The goal is not to abandon professional standards but to expose how those standards have been selectively applied and to insist that rigour, accountability and evidence can be defined through community-engaged, relationally grounded frameworks rather than solely through institutional gatekeeping that has historically excluded the very populations it claims to serve. The term ‘fugitive’ is deliberate: it evokes knowledge and ways of knowing that have been displaced, suppressed or rendered illegitimate by dominant institutional logics, yet persist through community practice, oral tradition and relational networks. Fugitive knowledge, in this sense, is not lost but in hiding, carried by those whom institutions have marginalised. For example, when Black teachers, under Jim Crow, covertly advanced liberatory curricula, masking compliance while equipping students with historical literacy and critical agency, or when faculty discuss ways of securing reproductive health training opportunities for learners in areas where such training is restricted or simply how to continue work on health equity when funding or institutional support is removed. The undercommons does not ask how to save or reform academic freedom; it recognises that academic freedom itself can function as a constraint, offering the illusion of intellectual openness while regulating which knowledge is permissible. Instead, it asks how to create conditions for intellectual life and resistance to flourish outside and against these very boundaries. This reframing resonates powerfully with what Rame-Montiel's participants described, that is, the strengths, well-being, safety, support and joy found in ‘(re)building, belonging, (re)connecting, revitalising and creating community and life beyond settler-colonialism’.1 Rame-Montiel et al's study enacts what Moten and Harney call fugitive planning where the real epistemic labor occurs not through the University of Calgary's formal apparatus but through LC, a Blackfoot physician who guided the research framing through indigenous paradigms; PR, a Métis scholar; and co-authors, who grounded the analysis in indigenous-specific anti-racism education.1 Their intellectual authority drew on institutional credentials and relational accountability to their communities together—a form of knowledge production the university can house but cannot govern. This constitutes what Moten and Harney would recognise as study: communal intellectual practice conducted within, but not fully of, the institution. Yet, the article's aim to produce actionable curricular guidelines surfaces a productive tension: Institutionalising this work risks domesticating it. The undercommons framework suggests that the most powerful elements LC and PR steward—relational accountability, cultural safety and community-grounded truth-telling—may need to remain partially illegible to the institution in order to retain their radical potential. This is the paradox of fugitive knowledge in academic medicine; it must be proximate enough to reshape practice, yet resistant enough to avoid being fully absorbed and neutralised by the very institutions it seeks to transform. What might this mean practically for all health professions education? It means supporting community organisations producing health knowledge beyond academic frameworks. It means protecting learner-led spaces that challenge biomedical reductionism and explore epistemologies from decolonial, disability, critical race, queer, feminist, Indigenous and abolitionist traditions. It means practicing collective autonomy through care and solidarity over credentialed competition. Rather than waiting for institutional permission that will never come, medical educators and health professionals might redirect intellectual energy towards these fugitive spaces, not as retreat, but as a deliberate reorientation of where transformative work happens. Rame-Montiel et al have given us a powerful articulation of what Indigenous anti-racism in healthcare could look like. The challenge is recognising that institutions designed fundamentally to constrain cannot authentically grant the freedom such work requires. Real academic freedom, if we can still use that term, emerges through collective practice, not institutional permission. Freedom thrives not by abandoning institutions but by refusing to let them remain the sole arbiters of legitimate knowledge and by building enough collective power, both within and beyond their walls, to hold them accountable to the communities they claim to serve. Far from a counsel of despair, this is a programme of dogged hope, one in which resistance and responsibility are mutually reinforcing and in which freedom is measured by our capacity to build health with, not merely study, the people most harmed by injustice. Zareen Zaidi: Conceptualization; writing – review and editing; writing – original draft. Bridget C. O'Brien: Writing – original draft; conceptualization; writing – review and editing. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Zaidi et al. (Wed,) studied this question.