Faculty are too often the major barrier to change in health education institutions and health systems. Faculty tend to view themselves as teachers, who teach, and the students as learners, who learn. However, this view is fundamentally oppressive. We can improve our ability to instill social medicine in health professions education if, instead of learning coming from a teacher bestowing knowledge on a student, learning comes through experiencing the reality of health inequity together, as students AND teachers, and working together to create new knowledge for all parties and the radical change that must follow it.
This may seem theoretical, but when protests erupted across Haiti on July 6 after the government’s announcement of significant increases in fuel prices, we knew that the content of our sixth annual social medicine course, “Beyond the biomedical basis of disease,” would ensure that students recognized the structural drivers of the unrest rather than accept the superficial news headlines, and that we needed more than ever to move forward with holding the course in Mirebalais, Haiti as planned (1). We began on July 9, despite the unrest, via a webinar by human rights lawyer Brian Concannon (2). We sought to come together as students and teachers (virtually for the first week and then in person for weeks two and three), sharing our experiences through discourse, to generate an understanding of the unrest in Haiti as being driven by structural injustice, rather than an oversimplified and racist narrative insistent on labeling Haitians as vicious plunderers (as a black American, this trick is all too familiar) (3). One of the foundational sessions in our three-week long social medicine immersion course is “Neoliberalism and Health Care,” which explores the complex web of international aid, from the International Monetary Fund’s structural readjustment programs to the real-life impact of tied aid. With this course under their belts, students would not fall into the trap of blaming Haitian leaders alone for the recent unrest, but would recognize the behind the scenes hand of global development paradigms.
One of the fundamental goals of our course in Haiti, and its sister course in Uganda (5), is not just to teach about social medicine, but to transform participants’ conceptions of how knowledge comes to learners. Having myself been immersed in the American academic medical system since 2003, and engaged in the Haitian system since 2009, I have both experienced and propagated a hierarchical banking concept of education (4). In this model of education, described and critiqued by Paulo Freire, teachers are narrators, and students are “receptacles” to be filled by teachers. Freire advanced, “Projecting an absolute ignorance onto others, a characteristic of the ideology of oppression, negates education and knowledge as a process of inquiry” (9).
In our social medicine course we promote a collaborative, interactive approach, where dialogue drives a synthesis of the existing knowledge in the room, so that “students” are learning from one another and the milieu around them, and the “faculty,” while facilitators, are as much learners as any “student” in the room. Perhaps not surprisingly, it is faculty who struggle most with this alternative conceptual approach to education, not students. And yet, the possibility of achieving health equity using a social medicine analysis depends on faculty being able to practice this model and model this practice.
Since EqualHealth’s first immersion course in Haiti in July 2013, over thirty Haitian and international faculty have served as teachers in the course, and have themselves evolved to fight the banking model paradigm. The evolution of one of these faculty members, Dr. Merly Robert, an infectious disease doctor and program director for the internal medicine residency at Mirebalais Hospital (6), is a powerful example of the type of faculty development that is central to EqualHealth’s mission and is made possible by the course. Dr. Robert has taught social medicine courses ranging from TB/HIV to narrative medicine to cholera, and also served as a Marshall Wolf Medical Education Fellow with EqualHealth (7). She has integrated the Freirean model over the past three years through her own pedagogical approach and through establishing a social medicine rotation for internal medicine residents at Mirebalais Hospital. Dr. Robert’s cholera session on July 16 was a dialogue with the students elucidating the root causes of the epidemic in Haiti – from lack of safe water to the UN troops that started the epidemic (8) – and a visit to the nearby base where the UN troops were stationed. Two students were so inspired by her session that they have started a project to elucidate perspectives of local community members and leaders who are seeking reparations from the UN for the impact of the epidemic, and who still have no reliable access to potable water now, eight years since the epidemic started. This is praxis at its best – reflection and action – and fundamentally disrupts the banking model of education.
As a junior faculty member, our social medicine course in Haiti has also become my main source of faculty development. It has helped me to build the courage necessary to avoid the hierarchical pedagogical approach typically used in medicine, to be more outspoken about the ills of my profession, which prioritize profits over patients, big pharma over access to live-saving medications for all, and access to care for employees of select, extremely profitable, corporations such as Amazon, JP Morgan, and Berkshire Hathaway, instead of a platform which treats health care as a human right, employed or not. Through working in Haiti side by side with my friends and colleagues who believe in a preferential option for the poor, to advancing a global Campaign Against Racism (10) with 21 chapters across 10 countries, to building a movement for health justice through the Social Medicine Consortium with over 300 alumni of the Uganda and Haiti-based social medicine courses and 600 members worldwide, transforming myself must be the starting point.
The key to our future success at EqualHealth, just as it must be for all faculty in the health professions, is to acknowledge and facilitate the capacity of our students as teachers, and our capacity as teachers to be learners. Change in this regard is more urgent than ever. I hope you will join me in refusing to be a faculty member who sedates the process of ending the oppression of students, patients, communities, and the Global South. We must reject the traditional, hierarchical pedagogical model that propagates silence, stagnation, and social inequity.
Note: In the weeks since the protests of early July, a burgeoning social movement has emerged, #challengepetrocaribe #kotekobpetrokaribea, which seeks accountability from the Haitian government for several billion dollars in international aid from Venezuela.