LAUREN PEREIRA-GREENE

134

74 Huntley Street Building

UCL Medical School

London

WC1E 6AU

Dear Professor Faye Gishen,

I am a third-year medical student, currently completing an intercalated degree in Medical Anthropology. I am writing to express concern around the disengagement between some medical students and efforts to decolonise the medical curriculum.

The meaning of ‘decolonisation’ is highly contested. Drawing on the work of you and your peers, I will define decolonisation as an ongoing process of transformation which aims to humanise and re-centre those who have been marginalised, and to make visible the impacts of power and violence (Allen and Jobson 2016; Gishen and Lokugamage 2019; Smith 2021; Wong, Gishen, and Lokugamage 2021). My ‘Decolonising Anthropology’ module has prompted a consideration of how we can reconstitute Western biomedical teaching as a decolonising practice. Drawing on anthropological perspectives, I would like to suggest ways to build upon current decolonising efforts and increase student engagement.

Firstly, I would like to thank you for the years of thoughtful work that you have contributed to the conversation on liberating, diversifying, and decolonising medical pedagogy. You have been at the forefront of adapting and improving the UCL medical curriculum, with a particular focus on the vertical Clinical and Professional Practice (CPP) module for which I was a student representative. Additionally, you are one of the key staff members who has been involved with the Decolonising the Medical Curriculum (DtMC) working group, which I joined in my first year. We both seem to share a passion for curriculum transformation. How can we include as many students as possible in this effort?

As a CPP student representative, I received verbal and informal written feedback on the module from many students in my year group. I was disappointed to learn that often students disregarded large portions of the module, assuming that it was ‘common sense’ and ‘low-priority.’ Students tended to study the content which focused on anatomy, pharmacology, and statistics, or what some may label as the ‘hard’ aspects of the module. This was often at the expense of ‘soft’ topics, such as ‘Equality, Diversity, and Inclusion’, which are more intertwined with the social sciences. Hard subjects are typically deemed more legitimate and academically rigorous, and such a tendency is reflective of broader cultural values and power dynamics. Whilst hard subjects often claim neutrality, these fields have been dominated by heterosexual, European males, whereas those from minoritised backgrounds (including women, and those who are indigenous, queer, poor, disabled, and/or non-European) have historically been excluded. Hard subjects are often associated with post-Enlightenment Western values such as empiricism, masculinity, objectivity, modernity, and rationality. A binary is created between this and ‘soft’ disciplines which supposedly centre more feminine and subjective ways-of-knowing (Cassell 2002; Winburn and Clemmons 2021). Commenting on clinicians, Arthur Kleinman (1980), a medical anthropologist and clinician himself, says, “Their tendency towards positivistic scientism and atheoretical pragmatism discourages attempts to understand illness and care as embedded in the social and cultural world. Their reliance on ‘common sense’ often masks ignorance of relevant behavioural and social science concepts that should be part of the foundation of clinical science and practice” (xii). Health can be understood through multiple lenses, and future doctors must learn that Western biomedical perspectives are not the only way of ‘knowing’ medicine.

Hseih et al. (2016) describes how final-year medical students were trained to write mini-ethnographies on a patient they were treating during medical placements in eastern Taiwan. Ethnography, a popular methodological approach used by anthropologists, involves embedding oneself within a specific setting and collecting qualitative data. It was found that participating in ethnographic research helped the medical students learn to effectively engage with people from a range of backgrounds by gaining knowledge of various cultures, otherwise known as developing ‘cultural competence.’ The concept of ‘cultural competency’ has been heavily criticised in recent years for its potential to catalyse stereotyping and othering, as well as for its oversimplification of culture and its focus on knowledge-acquisition (Beagan 2018; (Lekas, Pahl, and Lewis 2020). Several scholars have offered ‘cultural humility’ as an alternative which emphasises self-reflection and dynamic, continuous learning (Campinha-Bacote 2018).

Arthur Kleinman has developed an explanatory model which can be used to escape the limitations of cultural competency by engaging in dialogue to understand the patient’s explanations, expectations, fears, and aspirations in relation to their illness (Fadiman 1998; Kleinman, Eisenberg, and Good 1978). Using this framework, the medical students were able to grasp some of the cultural differences between illness explanations. However, only 15.6% of the students cared about their patient’s illness explanation. They largely disregarded ideas and practices that fell outside of Western biomedicine, and most of them did not pick up on the impact of health inequalities (Hsieh, Hsu, and Wang 2016).

If we are to begin decolonising medical education, we must train medical students to value and take-seriously their patient’s ways-of-knowing. Rather than introducing ethnographic practice in the final year of medical school, as done by Hsieh et al., I believe that early exposure to ethnography could ingrain an appreciation for the nuance surrounding health experiences. Medical students could be asked to write mini-ethnographies based on their placements throughout medical school, uploading this onto their online portfolios. Consequently, they can develop an appreciation for a range of perspectives over a number of years, helping to shift bias away from Western biomedicine.

The Year 2 ‘Eugenics’ and ‘Race in Medicine’ lectures by Dr Adam Rutherford comprehensively introduced the legacy of eugenic science as well as the issues associated with racialisation in medical practice. However, on my timetable last year, these lectures were highlighted a pale salmon colour, indicating that they were supplementary rather than compulsory. Faye Harrison (1997: 7) discusses how the institutional ‘accommodation’ of multiculturalist curricula adaptations are often side-lined as unscholarly ‘special interest trivia.’ This reflects the perceptions of many medical students I have spoken to who deem such content expendable, and less ‘academic’ than other topics. Understanding race and eugenics is critical to understanding Western biomedicine, as they have been used to justify discrimination and exploitation. For example, in the ‘Tuskegee Study of Untreated Syphilis in the Negro Male,’ racialisation was used to justify the denial of syphilis treatment to 600 men who were racialised as ‘black,’ leading to many deaths (Brandt 1978).

Eugenics refers to the idea that populations can be improved through the exclusion of certain individuals, and UCL played a key role in its “development, propagation, and legitimisation” (UCL 2021). At UCL, prominent eugenicists ran a laboratory for research into human genetics and eugenics. From 2014 onwards, several secret annual eugenics conferences were held at UCL which promoted neo-Nazi, white supremacist, and racist ideas (Bothwell 2018). Due to its strong ties with eugenic science and scientific racism, UCL has the responsibility to educate its students about the implications of these harmful ideas. Eugenics has had a profound impact on medicine and public health policies, evinced by the forced sterilization programs in the United States and Nazi Germany (Reilly 2015). Additionally, eugenic ideas influence contemporary medical practices, such as genetic screening. Yet, this significance is directly contradicted by the medical school’s decision to render these topics as optional. The Medical Schools Council recommends that teaching which challenges exclusions should be dispersed across the curriculum, rather than being contained within single modules. In doing this, decolonising frameworks would become naturalised and ingrained into clinical training (MSC 2021).

Farrell et al. (2019) surveyed medical students in England and found that almost a third of participants were given a mental health diagnosis whilst at university. Using the Oldenburg Burnout Scale, 82% could be classified as ‘disengaged’ and 85% as ‘exhausted.’ Most medical students are just trying to get by, and therefore do not want to take on anything that seems irrelevant to the passing of their degree. It is therefore of no surprise that many medical students are not actively seeking out or getting involved with decolonising initiatives. Additionally, the medical student population tends to exclude people from minoritised backgrounds, and therefore, many students may not feel that decolonising efforts have personal relevance to their lives (as they do not see themselves as individually affected by colonisation). This undermines how much colonisation has shaped modern life and reproduces the idea of decolonisation as an optional extra, rather than a process that must underpin everything. Decolonising does not have to be about adding extra content onto the curriculum’s periphery. Instead, the current content can be reimagined in ways that dismantle oppressive power structures. For example, the student DtMC working group have adapted many CPP lectures already to ensure that language and imagery doesn’t reproduce hierarchies. Such efforts should be extended to other domains of the medical curriculum. By embedding decolonising perspectives into all aspects of teaching, decolonising is accepted as a necessary and valuable aspect of medical training. Decolonising becomes a learnt way-of-being for students, rather than a ‘supplementary’ topic that they are unlikely to dip their toes into. In removing the need for students to take an active role in seeking out extra-curricular decolonising movements, decolonising becomes part of what they are already doing.

Decolonising medical education requires not just a reconsideration of what we teach, but also why and how. Usually, pre-clinical medical students are assessed through formal assessments written in English. This reflects a privileging of written English over other modes of expression, which was enforced globally during European colonisation (Ngũgĩ wa Thiong’o 1992). Davi Kopenawa (2013), a Yanomami shaman, describes how Eurocentric concepts of knowledge can clash with indigenous knowledge. Comparing his indigenous community to that of Europeans, Kopenawa says ‘Unlike them, I do not possess old books in which my ancestors’ words have been drawn’ (13). His words are deeply tied to cosmology, and he believes in verbally passing them down to the next generations. In my anthropology classes, we have discussed the importance of multi-modal forms of communication which facilitates cross-cultural knowledge production. Across the course, multi-modal assessment could create a space for more inclusive exchange and creative practices. For example, in CPP, students could be assessed through a critical discussion with each other about their clinical experiences. The weekly in-person CPP sessions already include a lot of discussion, some of which could be assessed throughout the year. This would take pressure off students by dispersing assessment throughout the year, rather than relying solely on a concentrated group of end-of-year exams. It also means that space does not need to be created in the timetable. Additionally, within the allocated CPP time, students could communicate professional reflections in the form of art or movement. For example, students could be asked to draw an image that summarises how they felt when interacting with a patient. This would prepare students well for clinical training, as they begin to value diverse ways of understanding knowledge and communication, which in itself could be considered as a decolonising practice.

In conclusion, decolonising efforts must be seamlessly integrated into the medical curriculum in order to involve the entire student cohort and lead to more transformative change. Decolonising the medical curriculum is necessary to acknowledge and address historical injustices, challenge Western bias, foster health equity, and enhance health outcomes. Medical students have a responsibility to minimise harm enacted on the patients they serve, and part of this must involve making all efforts to abate colonial violence.

I hope you consider my suggestions to increase early exposure to ethnography, weave decolonial thought throughout compulsory teaching, and incorporate multi-modal assessment. This facilitates cultural safety within medical education and healthcare settings by recognising power dynamics and appreciating diverse ways-of-knowing.

Thank you again for your continuing efforts, and I look forward to hearing back from you!

Best wishes,

Lauren Pereira-Greene

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Image photographed by Lauren Pereira-Greene