Recentering and Recognising: “Decolonizing the Medical Curriculum”

Sarah is a final year medical student at UCL, who joined “Decolonizing the Medical Curriculum” after finishing her IBSC in Medical Anthropology. Sarah’s involvement in DtMC started when she got in touch with UCLMS faculty about integrating anthropology into the curriculum, which led to a journey of critically examining the medical curriculum and eventually finding herself part of the decolonising movement.

Tina is a fifth year medical student at UCL. She was originally in Sarah’s year, but found herself enjoying her Global Health iBSC so much she went on to do a masters in anthropology before returning to medicine. At the same time Sarah was getting involved with DtMC, Tina and another student developed a proposal for a medical humanities society. This year, both of them joined DtMC and now make up half of the four-member team. 

Where did the idea of decolonizing the medical curriculum arise? 

Sarah: There has always been this movement at UCL: as a staff-student collaborative, the group worked on publications addressing gaps in funding or how guidelines are conceived, but students generally came and went with little continuity. The project was properly anchored by a final year student (Hope Chow) and two members of faculty (Amali Lokugamage and Faye Gishen). Anthropology gave me a new critical perspective and showed me how political medicine, making it apparent western biomedicine is a social institution with a lot of power. Such a perspective tends to get lost when you are in the [medicine] bubble. Decolonising was all about challenging established assumptions, and that’s what really drew me to the project.

Tina: I completely agree with Sarah. Social sciences really opened my eyes to medicine’s limitations: you can see situations where it works really well, but also ones where it is ill equipped to deal with the health problems at hand. Decolonizing is such a vast term, and it means different things to different people, which can in part explain why there is no centralised group working on this topic. In its original form, decolonization primarily calls for dismantling white colonial oppressive systems. The way we are using it in our initiative is by understanding how these historical legacies manifest themselves in medical education and we try to redress these power imbalances. But there is still a lot of debate around the word itself. As senior students at a central London medical school, we are surrounded by many important institutions. That itself is quite a good example of how geographical areas of power arise and just how concentrated knowledge is, within London itself. 

Sarah: Yes, higher education institutions are places of power. It’s important to recognise where we are speaking from. The working definition of “decolonisation” we’ve employed states decolonization involves two processes: 1) Recognising how forces of racism and imperialism have shaped what and how we are taught at university 2) Recentering traditionally marginalised perspectives, which may have been side-lined or even oppressed [1]. 

Why is it so important right now, more than ever, to decolonize the medical curriculum? 

Sarah: It hasn’t gotten more or less important, it’s just that more people are ready to have these conversations. With the disproportionate burden of Covid along with the Black Lives Matter movement ignited by the George Floyd murder, we see people opening up to these conversations as something that must be addressed. In the past, DtMC has had a bad reputation with the stigma of being too radical. But now it seems as if society is more ready for this movement. 

Tina: Visibility has a big part to play in it, whether it’s through social movement or whether it is Covid illustrating the stark health outcomes of different ethnicities. Its easier to see these issues when you are able to measure them. Measurability is a key part to this, and is maybe what was missing in the past. Now, a lot of reports are being published which consolidate this issue. For example, the MBRRACE report [2] shows how health inequality between women of color and the health outcome was so heavy. Sometimes when you don’t measure something, it becomes a bit of an invisible problem. Now that it is at the forefront, we are measuring things more. 

What are some of the more prominent colonial influences that many of us over look today and maybe need recognising and recentering

Sarah: This is where it becomes difficult to differentiate what is western culture from what is colonial, because these two have been so inextricably interlinked. One thing that does come up frequently is how we frame race. We need to recognise the process of racialisation is a deeply colonial process. Angela Saini in Superior [3] talks a lot about scientific racism and how the concept of racial categories emerged from a hierarchy of human types which was supposed to justify systematic oppression and subjugation of non-western people. We question to what extent race/ethnicity can be used as a proxy indicator for genetic or social variables, and look at the impact of using race/ethnicity in this way. 

Tina: There is no biological/genetic way of categorising race/ethnicity (more variation within a “race” than between “races”). Race/ethnicity is a social identity yet when framed as a medical risk it becomes entangled to biological indicators of racial differences, leading to a misunderstanding of what “race” is. A slightly separate point is that the relationship between environment, genetics and disease is highly complex and variable. In some diseases, e.g. Sickle Cell anaemia, genetic associations/patterns are clearer than other diseases where environment plays a strong role, e.g. T2DM. Whilst genetic associations can be made with a single disease, it’s invalid to extrapolate this out to a race. However, this is commonly done in both medicine and society which leads to the problematic essentialising/ pathologising of race. I think there is a significant information gap between scientific vs public understandings of genetics in general. Science communication on this subject is lagging. Improving public understanding of genetics would be one way of dispelling myths about “genetic basis of race” and rejecting scientific racism. 

The first area that sprang to my mind with regards to remaining colonial influences is global health: if you look across the world at key health indicators, you can see there is a clear divide between global north vs south, west vs non-west, however you want to frame it. You can also see names themselves e.g. “neglected tropical disease”, “the London School of Tropical Hygiene and Medicine” carry quite colonial overtones. As Sarah said, it becomes difficult to disentangle present and key issues today from their historical past. Some people don’t think such concerns are very helpful, and we should be focusing on the problem at hand. But how to do that when a lot of the global health institutions are based in the West? When a health crisis arises, it becomes very clear there is a lack of trust between less developed countries and western institutions. Ebola was an interesting example as it became a securitized issue. In fact, the US military was deployed in some parts of West Africa to contain that 2015 pandemic. 

Personally, I also think there is a problem with medical stereotyping and lack of diversity in textbooks. This is typically the case in dermatology. In a recent discussion group run by a student midwife, she pointed out similar issues arise in her curriculum: they are not taught to recognise clinical signs of jaundice/ cyanosis in neonates of colour. These issues don’t just affect medical students teaching, but all healthcare professionals. 

On the flip side, one can fear being seen as “difficult” if you raise the issue of race, or prejudiced by asking what’s considered “awkward questions”. On a recent placement, while taking a sexual history from a patient, I found it really difficult to ask about ethnicities/ nationalities of different sexual partners as it felt really essentializing and pathologizing. But when discussing with a doctor afterwards, I realised how not asking these questions is also a form of discrimination because it is causing inequity in opportunities to access healthcare. These complicated ethical issues are part of what is so interesting in medicine. Leading a workshop with Sarah, initially focused on cultural competency, but reframed as cultural safety, has given me the tools to talk about a complicated subject in a way that is both providing equitable health opportunities as well as keeping patients safe and not making them feel judged. 

Sarah: Culture safety is really important. In medical training, when we cover cultural competency, there is a lot of othering of non-western cultures, but also assumed inferiority of. Personally, this has become evident in case studies based on racial/ ethnic stereotypes which reinforce negative stigma e.g. afro-carribean middle aged men and schizophrenia. These perpetuate racist stereotypes within medical teaching. This also relates to medical paternalism, which justifies, for example, the dismissal of alternative and complementary medicines or attempts to make foreigners comply with what we consider is best for them. Patient centered care attempts to move away from this, but we think these efforts are not addressing the root belief on which such trends are based, which is intellectual and cultural arrogance. 

Should we be concerned about the consequences that may occur due to the way medicine has been shaped, and do these consequences exclusively affect BAME communities? 

Sarah: Yes. DtMC aims to rehumanize medicine. There is a lot of conversation surrounding empathy in medical training. It seems that many medical students and Junior doctors are becoming disillusioned by the toxic hospital culture in which there is a lack of time and funding. All these issues are within the realm of DtMC as well as we address what are the attitudes that make us less human, and less able to connect with patients. This affects all doctors and how they treat all patients. This is not just an “ethnic minority problem” but a problem in all healthcare, for all patients.

Tina: I remember attending one of your Black History Month events hosted by Dr Reuben Warren discussing the ‘Dark side of Medicine’, and he highlights several examples e.g. the Tuskegee experiment and the Dr J. Marion Sim’s exploitation of African American slaves during the speculum development. These examples highlight that social inequalities overlie health inequalities. Although the NHS is a publicly funded institution, these issues still exist. I think the thing to emphasize here is that social problems equals medical problems and vice versa. Racism against BAME is everybody’s problem, but this is not usually reflected in all practices. 

Sarah: The annual UK labour force report shows that healthcare professionals have a higher rate of burnout, anxiety and health problems. When we talk about ‘decolonizing’, we also talk about questioning power hierarchy and addressing how it has a damaging effect on individual institutions. These hierarchies leads to dehumanization of individuals at the bottom i.e. medical students. This culture of chains of commands leads to a really toxic work environment. 

   You address the six aspects of decolonizing the medical curriculum: the body, the curriculum the learning experience, the learning space, professional behaviour, and healing. How does your working group tackle this, and what has been working so far? Which aspect(s) do you find more difficult to address?  

Sarah: As a group, we have been fleshing out these different aspects by coming up with lists of resources that explore the theory behind. We focus mainly on the curriculum, exploring the link between what is explicit and implicit. But all these aspects remain integrated, though some like “learning experience” and “professional behaviour” are harder to quantify and control. 

Tackling the curriculum really involves analysing individual components of what is taught: we look at individual sessions within our Clinical & Professionalism module and think about how individual sessions can be reframed. We are aware real changes require long term and integrated changes all across the curriculum, but this is already taking baby steps. In my opinion, what’s most difficult to tackle is professional behavior, because medicine is such a conservative profession and there’s a deeply established culture with rigorous guidelines and expectations. Most medical learning takes place in hospitals with doctors already entrenched within that culture. Hopefully, we’ll see a real culture shift in the coming generation of doctor trainees. 

Tina: We realised we’re quite a self-selecting group, but we’re interested in the perspectives of other students and would really like to make this initiative a continuous student-staff collaboration. Decolonizing groups often get accused of “group-think”. It’s key we engage with people who don’t accept our ideas. Generally it is accepted racist independent events  occur between individuals. What’s more difficult to get across is the idea of structural racism i.e. the idea that a non-living thing can propagate racism through a long-term structural problem. Engaging with people who don’t think like us would also be an occasion to test ourselves because sometimes you don’t question your own assumptions. This would help us create a curriculum that increases critical consciousness. 

Hopefully we’ll be getting a UCL changemaker fund that will allow us to conduct research and involve medical students from a wider audience. Recently we hosted a roundtable where eight medical schools presented what their universities and courses were doing in this field. This was a great opportunity to learn about what other people are doing, what the difficulties they are facing are as well as how receptive their universities were. 

Sarah: We recognise our stance has some limitations, and because it’s deemed “radical”, some people will probably be turned off by the initiative for reasons they might not even understand- an intuitive gut response when it comes to issues linking racism, politics and medicine. There’s a lot of resistance to putting these three together. We’re lucky we had time to get a background in social sciences, whereas a lot of medics are busy, stressed and have little time to read outside the syllabus. Doing what we do takes work, especially if you haven’t been brought up with a similar perspective. We have to recognize it takes time and effort, and not everyone has that to give at the same time. Our idea is really to connect people, not alienate them. 

I’d personally like to know a bit more about how to ‘Decolonize healing’. Could you elaborate a bit more about this? 

Sarah: This is really about the way that healing is framed. Healing is a traditional art that is universal against different cultures, times and geographical spaces. We take for granted how colonial forces have shaped the way we think about healing today, in ‘Western’ society. The historical ideas of superstition, magic, and superstitious beliefs have been replaced by science, logic and rationality. This leads to a lot of the displacement of non-western healing practices. So I think we’ve lost respect for certain healing practices. What constitutes healing? What does it mean to heal? Is it the physical outcome? Is it quantifiable? 

We have moved away from the psycho- spiritual – social aspects of healing, which has now become more of an afterthought. There seems to be a narrowing of gaze of what constitutes healing and well being. 

Tina: It’s interesting that you outlined healing in terms of when it became colonized, when it became decolonized and how there are elements of recolonizing in the way we are appropriating a lot of practices. What comes to mind is ‘mindfulness’. A lot of this concept has been extracted from its original practices and has become capitalized and commercialised. It’s interesting that in the western world we have shifted our focuses on being proactive about mental well-being, when in fact these practices have existed way before the enlightenment and development of modern medicine. This concept, which was once part of a social practice, has really come into the medical domain. I think we need to ask. What does healing mean? It involves what you understand by health, by sickness, as healing is a process. We must be aware of the terminology we are using and the weight it carries. 

Sarah: In so many consultations, doctors respond to patients by saying “we have done all we can”. We hardly hear the word ‘healing’, which is replaced by the word ‘treating’. Healing isn’t just an active process but it can also be passive, such as just listening to someone. The way a patient feels out of a consultation can’t really be crunched into numbers. 

As medical students and future healthcare professionals, what steps can be taken right now to create tangible, effective change? 

Sarah: We all have a role to play in contributing to the medical school culture and environment and healthcare hierarchy. If we think something in the curriculum is mis- or under represented, we need to be empowered to realise that we do have influence. If we get enough people on board, we can be heard. Organising petitions, discussion groups etc., is a huge step forward. There is no sure way of guaranteeing results and DtMC has definitely felt some frustrations, but we just need to remember if we keep moving in this direction, something will tip and show results. We need to find like minded people and maintain this vision. 

Tina: I also think a lot of people do find it hard to find a group. But I would say now is a really good time to reflect on your position on society and your principles, and whether they have changed. We should reflect on our personal ethics and how we put it into practice. We must reflect: are you being consistent about your principles? Are you able to have those difficult discussions? A tangible change is very difficult as so many of these problems are deeply embedded and are very subtle, without a language to talk about them. We won’t see improvements years forwards, and we probably will have left medical school by then. 

If you could propose 3 concrete policy changes, be it at the level of the medical school, the GMC, or the government, what would they be? 

1. More funding into revising the curriculum and having specialist input at the level of the medical school. 

2. Reviewing policy around research itself, by incorporating different stages reviewing ethics, or providing guidance bringing in other less-thought of considerations when submitting a proposal 

3. Setting the standard of expectations of junior doctors at level of GMC and MRC 

In terms of the GMC guidelines, diversity is framed as a challenge. But we need to revise the guidelines through the lens of ‘how can we use diversity to enrich the guidelines and how we practice medicine’. Guidelines around representation within medical school faculty and widening participation amongst students would really help. We need guidelines to be able to meet criteria. 

At the government level, it would be great if we could fuel change much earlier in the national curriculum. Although these concepts are big, it doesn’t mean you can’t teach children these topics effectively. British history taught in school systematically omits black history. But we can compare this to Germany, where children are enshrined by the atrocities that were committed in the world war. We should think about how to teach history, so that students at university level will already have this critical consciousness in mind.

Do you have anything else to add? If you could get a strong message across to those in the UCL community, what would that message be? 

Sarah:  Don’t be afraid to push for space for issues that matter. If they matter they matter. Even if that space doesn’t exist, keep pushing for it and trust that you have the agency to create space. 

Tina: Be interested in this because you are part of this. You aren’t neutral, you aren’t objective, you are a member of this community. It shapes you and you shape it. Even if you don’t have the time to be involved in activism, you always have time to read up and learn about what is relevant to you. 

Interested? Join their Facebook group: 

facebook.com/groups/decolonisingmed 

References:

[1] Bhambra, G.K., Gebrial, D. and Nişancıoğlu, K. (2018). Decolonising the university. Pluto Press.

[2] Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. (2019). Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford 

[3] Saini, A. (2020). SUPERIOR: the return of race science. FOURTH ESTATE.

Transcribed and edited by Glenda Xu and Laure Mourgue d’Algue

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