Brocher Foundation, May 2016

Introduction

This three-day event took place at the Brocher Foundation Institute, Geneva, from May 17-20 2016, and was generously funded by a Brocher Foundation award. The organising team included Berna Gerber, Thomas Cousins, and Lizahn Cloete (Stellenbosch University), Megan Wainwright (University of Cape Town), Michelle Pentecost (University of Oxford), Ferdinand Mukumbang (University of the Western Cape) and Guddi Singh (Medact, UK).

Just down the road from the Villa Diodati where 200 years of Shelley’s Frankenstein was being commemorated (“a mythic expression of the anxieties of a world confronted with the growing power of science and technology”), a group of 25 scholars gathered at the Fondation Brocher. We had reason to consider anew the ways in which humanities and medicine might be reconciled, learned, and applied in ex-centric contexts between the global south and north, where distinctions between war and everyday life are constantly blurred. Our aim in bringing together a range of scholars from around the world and across many disciplinary — and transdisciplinary! — homes, was to consider new ways of bringing together humanities and social science knowledges with the training of health professionals.

The conversation emerged out of a network of practitioners and researchers interested in health professions education, starting at a workshop on “Building the Critical Health Social Sciences in Malmesbury, South Africa in 2015 organized by Chris Colvin (UCT) and Hayley MacGregor (Sussex), and taken forward at a second meeting with colleagues from around South Africa in March 2016 at the University of Stellenbosch. The Geneva conference covered three broad themes: (1) Health Sciences Curricula in Practice: Experiences of Teaching and Learning; (2) Critical theory and new pedagogies and (3) Praxis and theory: towards integration.

For an overview, links to the program, and speakers’ abstracts and biographies, see the report by our colleagues Megan Wainwright, Lizahn Cloete and Ferdinand Mukumbang.

In this conference report, we want to draw out some key reflections from the event that we consider to have application for medical anthropology, science and technology studies, cultural psychiatry, psychology and bioethics, beyond the remit of the conference focus.

‘Humanising the health sciences’: old wine in new bottles?

While this conference built on an established scholarship in health sciences education, medical humanities and critical pedagogies, it nevertheless made some important departures. The organisers’ deliberately provocative title about “humanizing” thrust the group into early debates on the notion of “humanisation” and the various social and political logics it brings with it, not to mention the wide divergence between meanings of “humanisation” across various national and local contexts, and the possible objects of “humanisation”: care, physicians, their training, or critical thinkers.

A critical humanisation?

A strong theme of many contributions concerned what we might call a critical orientation towards our own normativities. In the ‘chasm between theory and practice’, as Iona Heath put it, what is taken for granted? As Rolf Ahlzen eloquently reminded us, there is an ethic inherent to clinical practice: that the health professional must of necessity objectify the physical body, but that he must ultimately return from this ‘ontological excursion’ to situate the patient back in his or her person and societal context. As such the biomedical encounter is inherently paradoxical: the clinician must grapple with ‘biology and biography.’ Further, practitioners’ own biographies and biologies impact on their pedagogy.

Simon Forrest, describing his experiences with teaching sociology in undergraduate medical education at Durham, suggested that in place of an evangelical passion for “humanisation”, we should be making a stronger moral and political case in our training of health professionals, by exploring the social dimensions of health through situated examples (see also the UK network of Behavioural and Social Scientists Teaching in medicine BeSST, which is creating a core curriculum in Medical Sociology). Jill Gordon‘s take, drawing on her work at the University of Newcastle (Australia) in supporting Aboriginal and Torres Strait islanders’ physician training, was founded on an appreciation of the “client and extra-therapeutic factors” that so crucially shape health outcomes (instead of an assumption about the efficacy of medical techniques or specific therapies). Berna Gerber, chair of speech therapy at Stellenbosch University, described using her education in philosophy to open up communication and clinical judgement as vital dimensions of “humanisation” in working with health professionals. “Philosophy” as a clinical practice, then, might be a way to think of medicine less as a science (its own self-image) and more as a science-using practice of caring for the sick.

Caroline Hodge, a medical student at UCSF with a background in medical anthropology, described the marginal status of social science in the medical curriculum in California, but spoke up the positive possibilities that come from such marginality, such as student-led electives which can offer potent spaces for alternative narratives in the context of institutional investments in outcomes- and evidence-based approaches. Lizahn Cloete spoke powerfully about using Paolo Freire’s ideas in occupational therapy in support of prevention-oriented approaches to more integrated interventions for Foetal Alcohol Syndrome in South Africa. Megan Wainwright’s careful thinking through of the problem of addition versus integration of humanities and social sciences into health sciences education provided strong material that brought together many of the participants’ concerns from other contexts. One succinct intervention was to ask whether students should not be taught to read more, but to read better. Jane Macnaughton questioned the rationale that health professions education should be “humanised” in terms of the content that is taught, and made a case for a more experimental approach to education that allows for non-quantifiable processes and outcomes in the “processes of becoming” that unfold between patients and healers. Rather than devising new content for curricula, she suggested, we should be thinking about new kinds of research and modeling new orientations and relations in the practice of healing.

If these conversations sound to some readers like reinventing the wheel, it might indicate the necessary (re)turning and re-thinking that the politics of ill-being presents to established modes of thinking, teaching, and writing. Some suggested we take forward alternative conceptions of care, evidence, and the specificity of “context”; how this might translate into institutional practices of training across disciplines animated our debate.

By the end, the ‘humanisation’ of health sciences appeared less obvious as an endeavour than when we had started, producing more questions and challenges than solutions or answers.

Humanising health sciences in the North and the South

Experiences and material from South Africa, Iraq, Lebanon, Australia, Brazil, the UK, USA, and Canada, were exchanged and digested, prompting a set of debates about the circulations of biomedicine and its pedagogies between the global South and North. Margaret Lock’s assertion that ‘all medical knowledge and practice is historically and culturally constructed and embedded in political economies, and further, [is] subject to continual transformation both locally and globally’ (2008: 480) offers a useful starting point. What do the various health professions look like in each of these particular social and clinical conditions? How does the education of health professionals in these regions diverge in their clinical ambition or social or political grounding? Do these particularities affect biomedicine’s epistemologies across these contexts? It’s one thing to recognise that many Northern contexts increasingly resemble the Third World (see Meyers and Rose Hunt [2014] on “the other Global South”), or that privileged elites the world over enjoy first class health care; it’s another to think how those inversions might shape health professions training in Nigeria, Iraq, South Africa, or the USA. How does pedagogy navigate those transformations, or traverse these locales? For example, Seth Holmes spoke about American students who do not feel that learning about health issues elsewhere is relevant to those who will only practice in the US, while Michelle Pentecost and Thomas Cousins described how for South African medical students, the humanitarian crisis is often thought of as ‘out there’ in Africa. Do such political geographies matter for how we think of social sciences and humanities in relation to health professions and their pedagogies? Given that the global workforce in health care is highly mobile, how might new generations of students frame ethics of care and local responsiveness? Producing knowledge and the path to healing are not merely the preserve of labs, clinics, or classrooms in the North, but are redistributed through actually existing techniques and practices in many ex-centric locations.

Notions of humanity: conflict medicine and decolonisation

Omar Dewachi and Vinh-Kim Nguyen, in their presentations and discussions, focused attention on the need to redefine our framings of medical practice in a time when there is increasing ambiguity on what constitutes war or peace (Dewachi 2015, Dewachi et al 2014; see also Benton and Atshan 2016). While the impossibilities and devastations that war in the Middle East presents to health and wellbeing might appear radically opposed to medical practice in peaceful contexts, whether Southern or Northern, it emerged that there are many points of convergence in health professionals’ experience between, for example, informal settlements in South Africa, and war-time Iraq: violent trauma, stock-outs, and the effort to reconstitute norms and lives, bring easy notions of ‘conflict’ into question. These tensions offer new ways of thinking about the ordinary and the everyday in the context(s) of conflict medicine. Nurses, doctors, and other health professionals must bear the contradictions of the contexts in which they work. The 2016 junior doctors’ strike in the UK raised the question of conscience/conscientization: when does the practice of health care necessitate or eventuate an activist politics that exceeds the clinic? In South Africa, the question of ‘activism’ and ‘politics’ are never far from the surface in debates over health systems, resource allocation, and staff retention. Related to this is the question of how increasingly privatised models of care impact on different regions, and how this comes to bear on the way that health-care professionals ‘self-make’ in their vocations, and how this contrasts with the humanist concern that traditionally animates the subjectivities and techniques of the self called for by medical training. Similarly, the difficulty of publishing qualitative research in medical journals, and the frequent exclusion of qualitative questions and evidence in guideline development, means that patients’ voices and experience are lost to science and thus to improving clinical practice (Wainwright & Macnaughton 2013). If hierarchies of knowledge are to include patients’ experiences and other ways of knowing, is this shift to be effected through education or a broader culture change?

Pedagogically, we need to consider how concerns with inequality and social justice in health professions training articulate with students’ expectations of their responsibilities as health care workers. What might “politics” and “conscientisation” mean in engagements with “the curriculum”? How should we think, speak, and act across and between the various locales of our experience/expertise, both South and North, in the classroom or clinic or beyond it? What would it mean to “decolonise” medical curricula, amidst calls for “humanisation”? One response to these questions was the strong call to continually historicise biomedicine and medical practice, which can in turn reveal what present global circumstances mean for health, health care and healing.

Conclusion

Far from simply returning to an established conversation about the place of the humanities and social sciences in health science education, this conference brought old questions to bear on the contemporary moment in which we find ourselves trying to educate young health professionals. What was remarkable about the workshop was the way in which practice and experience were reflected on carefully, and how the philosophical and political implications of the concepts at stake could be explored. In addition, the combination of scholars from the South and North, emerging and more established scholars, humanities, social sciences, and clinical work, made for an energising and rewarding set of conversations.

References

Benton, A and Atshan, S. 2016. “Even War has Rules”: On Medical Neutrality and Legitimate Non-violence. Special Issue: The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval.  Culture, Medicine, and Psychiatry 40 (2): 151–158.

Dewachi, O. 2015. Blurred lines: Warfare and health care. Medicine Anthropology Theory. 8 July 2015.

Dewachi, O, Mac Skelton, Vinh-Kim Nguyen, Fouad M Fouad, Ghassan Abu Sitta, Zeina Maasri, Rita Giacaman. 2014. Changing therapeutic geographies of the Iraqi and Syrian wars. The Lancet 383 (9915): 449–457.

Meyers, T and Rose Hunt, N. 2014. The other global South. The Lancet 384 (9958): 1921–1922.

Lock, M. 2001. The tempering of medical anthropology: troubling natural categories. Medical Anthropology Quarterly, 15(4): 478-92.

Wainwright, M & Macnaughton, J. (2013). Is a qualitative perspective missing from COPD guidelines? The Lancet Respiratory Medicine, 1(6), 441-442.