THE CUTTING EDGE: Health humanities for equity and social justice

Self-inflicted wounds: the problem with the health humanities

The health humanities are often regarded as a type ot intellectual and emotional balm, a salve that may be spread liberally, not only over the injuries from disease but over the dehumanising wounds caused by health care. Those wounds are inflicted by implicit biases, stigmatisation, inequities in treatment, unequal access to services, the impersonal conveyor belt-like character of patient care—and by the brutalising influences of training in the health professions. In contrast, the health humanities have been viewed as a way to get back in touch with our emotional selves, our humanity, to rekindle our sense of purpose and idealism in serving others. The humanities—the creative visual arts, literature, music, philosophy, sociology, anthropology, and history—have been advocated as a means of teaching empathy and communication and observation skills, increasing self-reflection and reflective practice, and enhancing the wellbeing of health professionals. While these goals are all laudable, the predominance of biomedical, technico-rational ways ot knowing in health professions education and health care has frustrated their realisation.

Furthermore, even the most passionate proponents ot these humanistic approaches often unwittingly contribute to weakening their own positions through self-inflicted wounds. In an effort to introduce the health humanities into the education of health professionals, there often is no overall conceptual objective other than some vague, even pious, notion of‘feels good,’ ‘self-reflection,’ and ‘getting in touch with our inner healers.’ Even the language that one hears from the most passionate proponents tends to belie the value of their proposals: ‘soft,’ ‘touchy- feely’ subjects in contrast to the ‘hard’ clinical and biomedical sciences; the defensive, almost apologetic arguments for inclusion of the humanities in the curriculum, the lack of conceptual rigour in the design ot activities, and the lack of critical questioning of methods to determine how the effectiveness ot such activities may be measured. Together, the challenges of legitimacy and these selt-inflicted wounds ensure the banishment of the health humanities to what Catherine Belling (2010) terms “the decorative edges ot the curriculum.”

In contrast to many of the goals mentioned above, we propose that the health humanities play an essential role in the education of health professionals, particularly in the areas of equity' and social justice, in two ways: first, by introducing a critical lens through which processes, values, and practices of health professions education and health care itself may be viewed; and second, by opening up spaces for reflection, dialogue, and action in addressing social injustice and oppression. Lev)' and Sidel (2006) define equity in health as “the absence of systematic disparities in health (or in the major social determinants of health) between social groups that have different levels ot underlying social advantage or disadvantage.” Health equity as a remedy to social injustice emanating from inequity has been defined as the elimination ot health disparities. Health equity comprises aspirational principle and vision, shaping practices as the action needed for current structural change to occur (Stone 2013). This view has been debated in global perspectives of justice and health with a recent preference for Amartya Sen’s (2005) pragmatic slant towards justice in terms of capabilities, further refined by Martha Nussbaum (2011). Sen asserts that good health must include an evaluation of the freedom a person may have to function. Beauchamp and Childress (2008) add that the allocation of goods and services, rationing, and setting priorities must also be considered (Hatchett et al. 2015).

The lack of education to address disparities in health care has been acknowledged as a deficit in medical education, where physicians have been reported to show a “lack of knowledge and skills in working with socio-economically disadvantaged patients” (Hudon et al. 2016: 2). Teaching in this area has traditionally focused on content material covering the ‘social determinants of health.’ In this approach, students learn lists of social characteristics (e.g., race/ethnicity, gender, socioeconomic class, immigration status, etc.) as a way to explain ‘naturally’ occurring causes ot disparities in health care and outcomes, instead of prompting learners towards action and activism to address root causes (Shanna et al. 2018). More recently, the impetus has been for “wider adoption ot the materials and methods ot social medicine which studies the health of collective groups of people along with the power relationships between those groups and the institutions that impact their health” (Hixon et al. 2013: 162).

An examination of social justice and equity¹ in health humanities necessitates reference to the concept of ‘structural violence.’ Structural violence refers to injustice and inequities “embedded in ubiquitous social structures and normalized by stable institutions and regular experience” (Winter and Leighton 2001: 99). These social structures, composed of social relations and political, religious, or cultural (including medical) arrangements, are ‘violent’ because they subjugate people and communities, restrict their agency, choices, and freedom, waste their talents, knowledge, and skills, and debase their dignity and humanity. They violate. In doing so, they' perpetuate discrimination and oppression by causing, illness, injury, suffering, and death. There has been substantial writing on structural violence and the politics of blame (Berns 2001; Parker and Aggleton 2003; Farmer 2004; Castro and Farmer 2005; Farmer et al. 2006). What is needed, however, is an exploration of how educators may prompt relatively' privileged health professions students and practitioners to reflect deeply on the social injustice and inequities created by' structural violence (Farmer 2003; Rylko-Bauer and Farmer 2016).

Also missing is discussion ot a means to guard against abstraction, i.e., to prevent teaching for social justice and equity from becoming an intellectual exercise confined to the classroom with no real-world effects or outcomes. We call tor exploring these constructs in meaningful ways through embodied practices—interactions in the learning environment—that stimulate a provocative positioning and interrogative stance. Embodied practices entail patterns of ongoing interaction between an organism and its physical and cultural environments, where understanding is deeply embodied. Human interpretation and reasoning rely' on sensory, motor, and affective patterns and processes to shape understanding ot, and engagement with, the world (Johnson 2015). These ways espouse not just dialogues on equity and justice but engagement through action, participation, activism, and advocacy through a pedagogy that is based on disruption, distraction, destabilisation, and discord to understand the interrupting effects of dis-ease on human health and flourishing.

Here, dis-ease represents a state of discomfort, disequilibrium, or instability that may precede and/or cause the manifestation of ill health. It is the intersection between a patient’s subjective experience of ill health (illness) and the medical establishment’s hegemonically based descriptions of ill health as ‘disease’ or ‘disorder’ (Wilkinson 2017). Structural dis-ease may be a harbinger of structural violence provoking disease and illness. For example, forced migration usually affects the most vulnerable in a nation: the stress and suffering provoke destabilisation of health in individuals and groups, thus creating disease and illness. This dis-ease—and the resultant illness—accompanies people into new contexts and perpetuates their vulnerability and disadvantage.

The effects of structural violence have been referred to as “social suffering,” the lived experience of distress and injustice that lays bare the inextricable links between personal and societal problems (Kleinman 2000). Frank (1995) refers to a “pedagogy of suffering” in which patients’ narratives make their suffering evident and visible, while teaching occurs through exposure to these experiences. He refers to the humanities in medicine as a “sociology of witnessing,” where the unmasking and witnessing of suffering create discord, disruption, and dis-ease, compelling the witness to account tor, or to acknowledge, the patient’s active role and participation in the illness context or drama. Otherwise, the patient is merely a silent enduring body, or worse, a system or organ being acted on by an imbalance of social forces (structural violence), in addition to the physiological imbalances leading to disease manifestation. In the view of postcolonial philosopher Gayathri Spivak (Spivak and Morris 2010), this would be an instance of the subaltern (marginalised or subjugated people) attempting to raise her voice while remaining unheard because of a lack of a context in which her voice may be perceived. Sharma (2018: 1), building on Spivak’s assertions, considers that “the positioning of the patient as ‘subaltern’ can provide channels of resistance against traditional power asymmetries.” We contend that for the ‘subalterns’ (i.e., subjugated and oppressed voices/patients) to be heard in the context of medicine, disruption, discord, and distraction must be included in the fabric of medical thought and practice. Where it concerns health professions education, this must occur in the very weaving of this fabric itself.

Equity' and social justice lose their rigour if they are static concepts, both idealised and idolised; or aspirations to be achieved over time rather than tangible, pressing concerns. As social constructs, equity and social justice are in danger of being abstracted away from actual suffering and the power structures (within the medicine and health care establishments) that produce such suffering. This engagement must extend from verbal dialogue to include embodied dialogical engagement in corporeal (patients’ and doctors’ physical bodies) and institutional spaces (health professions schools and related health contexts). An example from medical education is Rachel Prentice’s examination of how surgical training as a structured environment prepares students for the embodied lessons taught by a surgeon (Prentice 2007). While patients enter and leave the contexts of medicine, medical professionals are consistently present and have their thoughts, ideas, and identities shaped by the context. In the absence of disruption and reflection, they will perpetuate the structures that create social inequities and injustice within the establishment.

Disruption of such habits can cause gaps to create a context for the subaltern’s voice to be heard. Spivak demands that those in power establish these kinds of contexts. Patients have been lulled into social control through unconscious collusion with the power structures in the medical establishment via “governmentality” (Foucault 1991). The relationship between patients (as subjects) and hospitals and medical establishments—including medical schools—(as institutions) perhaps most tangibly represents the Foucauldian view of biopolitics, the extension of state or sovereign power over both the physical and political bodies of a population. A Foucauldian perspective of governmentality accounts tor how people unwittingly concede and subject themselves to be acted on as ‘patients’ (an identity position), although the exercise of sovereign power does invite resistance:

Human technologies involve the calculated organization of human forces and capacities. Relations of hierarchy, from age to educational qualifications and accreditation, locate individuals in chains of allegiance and dependency, empowering some to direct others and obliging others to comply. Mechanisms of reformation and therapy provide the means whereby self-regulatory techniques may be reshaped according to the principles ot psychological theory. As networks form, as relays, translations and connections couple political aspirations with modes of action upon persons, technologies of subjectivity are established that enable strategies ot power to infiltrate the interstices of the human soul.

(Rose 1999: 8)

In medicine, patients’ voices are typically silenced. Their position of powerlessness is intensified where patients carry the mantle of other silenced identities such as poverty, gender, race, or class. Equity is severely threatened because they are not only silenced but also invisible. Their issues do not exist because they do not have a space in the context. Their voices resonate at a different pitch so they are not heard, and they reflect light at a different wavelength so they are invisible where their light is not reflected. Equity' and social justice in the health humanities should aim to foster and teach health professionals how to bend and shape contexts to catch the invisible wavelengths of light and vibrate at frequencies that allow silent voices to be heard. We advocate tor teaching for equity' and social justice. Health professions education tor social justice and equity' must take an accountability and advocacy perspective. It does so by engaging concepts and approaches drawn from disciplines in the humanities and social sciences, such as philosophy, critical theory, literature, poetry, the visual and performance arts, sociology, anthropology', and history', while looking at health, illness, health care, and the education of health professionals (pedagogy') in new and generative way's. We propose that the critical health humanities may in part achieve these goals by fostering the development of a critical consciousness of self, others, and the world. This praxis combines both content and critical pedagogy, using numerous techniques and concepts explored in depth below.