Questioning postcolonialism and neocolonialism in decolonising medical education

Another way in which the humanities act as the ‘sharp edge’ of education is by questioning concepts, practices, and motivations that are taken tor granted as ‘inspirational’ and well meaning (Bleakley, Bligh, and Browne 2011). An example ot this trend is the rapid development of global medical education as a discipline in the West. This often is characterised by two related approaches: first, in what has been described as neocolonialism in medical education (Bleakley et al. 2008), where Western medical educators work to ‘correct’ perceived underdevelopment in non-Western global contexts through the introduction ot ‘more advanced’ forms ot Western medicine (i.e., ‘the West is best’ approach). Second, where concepts deemed ‘universal’ in Western medical education, such as teaching and assessment methods, communication styles, and even notions ot empathy and reflection, are introduced in an unmodified and non-critical form into non-Western health environments (Nguyen et al. 2009; Naidu and Kumagai 2016). The unfortunate end result that accompanies much self-congratulation on the part of educators is but a newer form of intellectual or educational imperialism.

Bleakley, Bligh, and Browne (2011) address this ‘postcolonial’ dilemma in medical education by noting that knowledge may be culturally legitimated in spaces left by withdrawing colonising nations. They warn that Westerners must be cautious about exporting a homogenised brand of Western medical education that may thwart locally adaptive practices, while research funding for medicine is unfairly skewed towards research that investigates medical conditions dominant in the West. Referring to these trends as “imperialism through the back door,” Bleakley and colleagues recommend a reflexive approach suggesting that Western medical educators develop new ways ot reflecting on what they are doing when they advocate tor the spread ot Western curricula, approaches, and teaching technology.

We add that a postcolonial view using this lens would also ask medical educators in the global South (developing countries/the Third World, etc.) to cultivate—in research, education, and practice—resistance to the unreflective adoption ot Western pedagogies: curricula approaches and teaching technologies. The latter is perhaps a more challenging prospect because it requires resistance to the insidious forces of empire bolstered by economic (capitalism), linguistic (global dominance of colonisers’ languages, e.g., French, Spanish, English), and cultural (Western music, art, and literature) factors (Roy 2004). It requires colonised peoples to reject or at least externalise conceptions of themselves as ‘the other’ in their own eyes (Said 2003). This form of resistance might already be emerging in medical education and research through what Homi Bhabha (2004) refers to as “mimicry” or “sly civility.” Here, colonised peoples consciously but ironically simulate the actions, views, and philosophies of the colonisers for the purpose of gaining access to colonial spoils. This may be characterised by researchers from the global South participating in global collaborative projects and changing ideas from within. Increasing numbers of students from the developing world enter Western medical schools subverting Western ideas imposed on them from within the colonisers’ worlds and institutions. As these researchers and students become more empowered, so their resistant identities may emerge and develop leading to heretofore hidden traditional health practices gaining recognition.

The largest medical research funding sources tend to originate in the West with funding calls generally requiring developing country researchers to collaborate with Western researchers. Often, such calls specify that lead investigators be Westerners, creating skewed partnerships in research and global medical education that favour Western researchers and students and Western ideas and practices (Bleakley, Brice, and Bligh 2008; Karle et al. 2008; Adams et al. 2016). In addition, many global health programmes offer medical students paid or funded experiences in developing health contexts and access to ‘data’ gathering or observation opportunities in developing countries that established local researchers would take years to access for lack of funding and resources (Nguyen et al. 2009; Adams et al. 2016). In such instances, students need to be enlightened about how their experiences and observations may be come across as intrusion or ‘gawking’ in the eyes of local people (Conrad et al. 2006; Ackerman 2010; Abedini et al. 2012), echoing ‘othering’ and emphasising of difference by Western ways of seeing (Said 2003). In these contexts, students might begin to see their Western mentor-researchers not as the great white hopes or saviours who descend to discover what the true nature of local medical and health issues is, but people, who, by virtue of racial, class, political, and economic privilege, are able to impose their neocolonial will on people—communities and nations who have yet to shed the yokes of the original colonisers.

There is no social justice and equity without reflexivity: how does who I am influence what I see and how others see me?

As neo-colonisers, Western medical researchers can build lucrative careers and celebrity status in their disciplines globally, in what might be called the ‘appropriation of data’ in a colonising setting that controls access to medical data, health trends, and funding tor research. A social justice and equity perspective would demand that Western researchers and their students assume an accountability by taking a reflexive stance to consider how their positions of privilege afford them access to power and status (Finnegan et al. 2017). They would be obliged to confront how people in non-Western contexts are subtly cajoled or even coerced to compromise and relinquish their cultural knowledge, ideas, bodies, and lives for the sake of‘global’ medical research. Perhaps this may be tempered by teaching reflexivity, so that health profession students may interrogate their own perspectives as well as the social structures (socio-cultural, historical, and economic) by which their gazes, lenses, positionalities, and perspectives are shaped. This could in part entail: first, equipping health professions schools with the tools and technology to deliver this imperative; second, addressing the mismatch between the skills taught in most schools and those needed to improve fragile health systems and finally ensuring that health professions schools that strive to eliminate health inequities should ‘walk the walk,’ adopting progressive practices to institutionalize equity.

(Drobac and Morse 2016: 702)

Again, this behests the challenge to confront silence and invisibility from within social structures that do not yet possess method or means to perceive what needs to be seen or heard (Spivak and Morris 2010). While concepts of individual justice focus on an individual’s rights and obligations within an organised state, the tenets of social justice expand these rights and obligations to include the responsibilities of society to its members and its members’ responsibilities to each other (Hixon et al. 2013).

Putting the health humanities under a critical gaze

While the health humanities may be engaged productively in health professions education, this should be scrutinised critically. For example, a popular means of introducing the arts into medical education is planned activities around a visit to art museums (Bardes et al. 2001; Dolev et al. 2001; Reilly et al. 2005; Kirklin et al. 2007; Gaufberg and Williams 2011). The goals of such activities range from sharpening observational skills and clinical reasoning to improving health care professionals’ wellness and compassion. Although such activities probably meet most, if not all, of their stated objectives, they also run the risk of reinforcing existing and traditional power hierarchies through an unquestioned approach to the arts. In the same manner that an uncritical reliance on the Western literary canon as educational material in the health humanities may reinforce traditional notions of art and aesthetics, a lack of care and thoughtfulness in introducing art into education may restrict one’s perspectives and questioning to certain culturally sanctioned “ways of seeing” (Berger 1972), instead of prompting learners to question or critique societal values and norms.

Making strange

Expanding on the theme ot disruption, the health humanities can play an additional role in health professions education: that of‘making strange.’ One ot the most powerful functions of modern art is to distort perception of common things, events, people, and things in order to prompt a ‘re-imagining’ of them. Although the idea of‘making strange’ has been used in art and literature for millennia—from the satires of the Greeks and Romans to the surrealist vision of Rene Magritte—the conceptual articulation of this phenomenon was first made by the Russian Formalist Victor Shklovsky (Shklovsky and Sher 1991). Shklovsky maintains that habituation in thought naturally leads to what he called “automatic thinking” in which objects, places, events, and individuals “fade away” and become inaccessible in their uniqueness to consciousness. Art functions to renew awareness ot these things by distorting perception so that they are viewed afresh. He calls this process “estrangement” (ostranenie):

[IJn order to return sensation to our limbs, in order to make us feel objects, to make a stone feel stony, man has been given the tool of art. The purpose of art, then, is to lead us to a knowledge ot a thing through the organ ot sight instead of through recognition.

By ‘estranging’ objects and complicating form, the device of art makes perception long and laborious.

(ibid.: 6)

Inspired by Shklovsky’s theories, the German playwright Bertolt Brecht (1964) employed the concept ot the “alienation” or “A-eftect” in his sociopolitical dramas to disrupt audience identification with the protagonists and to lay bare the actual mechanics ot the staging and production. In doing so, the drama creates a sense of alienation in the audience and forces them to question the seeming naturalness ot conditions in the play—and by extension, in modern society. Unlike Shklovsky, Brecht attributes this seeming naturalness not to the automaticity of human perception, but to the distorting torces ot capitalist economies (ibid.; Kumagai and Wear 2013). Literature, film, poetry, painting, and sculpture—trom Kafka’s Metamorphosis to the paintings of Frida Kahlo and Francis Bacon, to short videos on YouTube—can be used in medical education to ‘make strange’ seemingly natural ways of looking at patients, doctors, and the practice of medicine in order to renew our vision of health care in ‘rehumanised’ forms (ibid.).

 
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