and act like it never happened
they come back
and act like they never left
– “ghosts” by Rupi Kaur
Global health is on the rise. Is that a good thing?
The call for a more global medical curriculum — one that not only recognizes, but prioritizes health issues that transcend national, political and cultural demarcations — is coming from all sides. American medical student interest and participation in international electives is considerable, and surveys indicate that its growth has accelerated in recent years. Substantial evidence demonstrates that medical students with greater exposure to global health issues are more likely to enter primary care and practice among medically underserved communities. Students who participate in international medicine electives report significant improvements in physical exam skills, recognition of disease presentation and personal growth. More often than not, students benefit measurably from exposure to both knowledge and hands-on practice relating to global health.
Perhaps because of these positive effects on students, outcomes for the communities who host medical students are often approached uncritically. When they are examined, ethical and pragmatic evidence reveals that enrichment for students and the investment of external resources do not necessarily equate to long-term improvements in the health of communities. Global health faces the potential to reinforce already-entrenched power inequalities — and not only in terms of economic wealth. Inequalities persist between the historical colonizer and historically colonized, between those with a mission of salvation and those with a legacy of being “saved.” These distinctions remain relevant today. For decades, the approach of global health’s biggest players was generically geared towards eradication of disease in a population known chiefly as primitive and diseased, from spaces known chiefly as virulent. The ideas that provided a foundation for global health, largely through colonial medicine, have tremendous residue today.
To say that global health work by medical students is inherently patronizing or irresponsible is reductive. Rather, the context that surrounds effective interactions demands reflection, humility and long-term accountability from its participants. It demands prioritizing host communities and working towards a vision of redistributed power, not just vaccines. As it stands, the “global health canon” of many organizations fail to address these issues. We need to learn — and our medical schools need to teach us — how to think critically about precedent and strategize for the healthcare landscape that we want to see.
Shifting to a more egalitarian approach is not a natural consequence of compassion or hard work. It requires active thought and progressive practice from those involved. Though that seems daunting and intangible, we can begin within our own spheres of influence to impact the discourse and practice of global health. One approach is through incorporating frameworks of anti-oppression, in terms of all its axes (racism, sexism, LGBTQ discrimination, etc.), into the training that emerging leaders in global health will receive.
What is oppression and why is it related to global health?
We can think about oppression as repeated mistreatment on an interpersonal to systemic level, ranging from discrimination to genocide to mass incarceration. Oppression reinforces existing societal hierarchies and systems that diminish the worth, capacity, treatment or perception of a group.
Historically, the health systems in many low- and middle-income countries were based in oppressive Western force. For example, the International Monetary Fund’s Structural Adjustment Programs (often considered ineffective) radically overturned health structures and injected free market principles into health care. These top-down changes had consequences on countries’ abilities to reform and ultimately serve their citizens. Recent, high profile examples of poorly designed interventions include the privatization of water in southern Africa and installation of groundwater wells in Bangladesh. The former is widely recognized as a major destabilizing force in these economies while in the latter, wells were installed without checking for arsenic in the soil, resulting in the largest known poisoning of a population in history.
That these problems began in the 90’s and affect millions today is testament to the durability of oppression. In these cases and others, the defense of “good intentions” is founded in the idea that the intentions of the powerful are somehow more valuable than the lives of the affected. It also suggests that more catastrophes need to happen before these concerns bear weight. It’s a poor argument.
Anti-oppression is more than recognizing structural violence: more than monitoring micro-aggressions and more than checking privilege. It is working to reject crooked, harmful systems and build new ones.
How can anti-oppression be applied to global health training?
Engage our own identities
Part of the work of evolving as an activist involves deep, honest engagement with the realities of our own personal place in the world. We must learn to be in conversation with our own individual identities, which can be dynamic and do not necessarily require labels. We are all in a constant state of growth. We are all learning ourselves. Thus, we ought to wonder: how does my understanding of my own race, ethnicity, gender, sexuality, religion, birthplace and class ground and guide my activism? What is the body that I’m in and whom do I represent by nature of my existence?
The practice of locating our personal identities should be incorporated into global health training; it gives us richer insight into the dynamics of our relationships and our organizing. Everyone, from a rural community health worker to an American student, can align themselves with this movement. The chasms of power and privilege between us are wide — yet we must complicate our current understanding of them and realize that these chasms extend far beyond poverty and wealth. The more nuanced lines of distinction between us make collaboration that much more urgent and complex. For example, if you identify as queer, how will this part of your identity impact your ability to work in a country where homosexuality is criminalized? Or, how is your particular ethnicity going to affect your capacity to make shared decisions with a community of color? Can you call your organization “global” if the majority of your American staff consists of highly educated, cis-gendered, straight, affluent, white women?
In “Sister Outsider,” Audre Lorde argues that we must “develop the tools for using human difference as a springboard for creative change.” To call social justice and human rights the uniting, equalizing force behind our work requires more of us than we have thus far realized. Unraveling layers of difference within our movement and its varied intersections will not divide us, but rather make us stronger. Recognizing the nuances of our narratives will help us build new systems that reject savior/victim and donor/recipient dichotomies. As we work through questions of self, we open ourselves to others. We add dimension to a flattened story.
Be aware of the space that we occupy
We can translate this consciousness of self into action by being cognizant of the “space” that we occupy. The concept of space speaks to the need to pay attention to our positionalities and privileges — or lack thereof — and how they impact our roles in social justice movements, conversations and actions. In other words, we have to practice a critical awareness of the implications of our presence. As a concept, space is related to the idea of voice. “Taking up space” could refer to a physical presence, such as standing front and center of a protest. Or, it could be understood as something more intangible, such as speaking out on an issue to the point of silencing others, whether intentionally or not. This becomes problematic when we take up space that should belong to others. Realizing when to move forward and when to move back calls for humility, empathy and self-awareness, qualities that many global health activists already seek to embody.
This idea applies to global health in several ways. When we work in other countries, we have to consider our volume and impact on different communities. When foreign actors develop international programs or work with local NGOs, they occupy space by becoming a player in existing social, economic and political structures. They both affect and are affected by existing health systems. Framing an external partner as an ally suggests that they reinforce the work of local organizations rather than impose paternalistic solutions or financial conditions on funding. We can also use this framework to think about the act of storytelling. Many students write blog posts that have the potential to center their personal experiences in the global health arena. But how often do students share the stories that have already been written about and by the communities in which they work?
Developing vigilance to representation and space at all levels defines the work that needs to be done to overturn inequities and equalize power. This requires seeing communities not just as mere “beneficiaries” but instead as people. Medical education in a global context would benefit from an anti-oppression framework, which involves seeing global medicine as an exchange based on long-term partnership, mutual learning and collaboration. Successful programs do not silence communities, but rather ease the burdens of survival.
Diversify the global health canon
Global health education should better incorporate the history of America as part of its training. Recognizing America’s struggle with racism, sexism, xenophobia and homophobia as part of the global health project would not only help mitigate the false divide between global and local health, but also change the way we treat health issues. Social medicine and global health are often seen as separate spheres, when in reality they are more closely related than we acknowledge. The confluence of oppressive “-isms,” disease and American history directly influence the marginalization of people in the U.S. and abroad. A recent example of the need for this kind of application became evident during the Ebola outbreak, when the legacies of racist representation of diseased black bodies re-emerged through American media and people’s reactions to the crisis. If we had resisted xenophobia and racism from the beginning of the outbreak, perhaps the response to this crisis could have been more effective.
One way to fill the gaps that exist in teachings of global health is to expand and diversify our bookshelves. Reading and discussing figures like Paul Farmer, Nick Kristof and Jeff Sachs might serve as an entry point, but stopping with them alone will do a disservice to our cause. There is so much more out there.
Mainstream anti-oppression training into medical education
Of course, anti-oppression frameworks need not be limited to the global health arena. As medical educational standards evolve to reflect the significance of diversity and health inequities, it is critical that our educational institutions push frontiers in these areas by learning from each other and from their students. For example, at Albert Einstein College of Medicine, a collective of students emerged during the Black Lives Matter movement and asked for implicit bias training for all incoming students, something that was implemented this year for the first time; a similar program is in development at the Warren Alpert School of Medicine. The University of Rochester School of Medicine holds an elective African American History seminar, which has focused on unpacking stereotypes and how those stereotypes translate to unequal health outcomes. There is a nationwide shift towards teaching a model of cultural humility and structural competency instead of cultural competency. These are huge strides. Rather than being siloed or used merely to fulfill a requirement, they should be expanded and mainstreamed. They should be celebrated.
The Bottom Line
This is written as much out of reflection as hope. The possibility of new standards for global health work is not only conceivable, but underway, and we must redouble our efforts towards a concerted approach. Combating pervasive oppression — acknowledging, resisting and abolishing it — is necessary for patients and their communities, in the U.S. and abroad. If these are people we wish to care for and stand with, we need to disentangle the forces that have thus far determined who has a right to live; we need to rescue ourselves from complicity.