Rethinking global health from south and north: A social medicine approach to global health education

ABSTRACT

This study examines efforts to integrate social medicine into global health education and its potential to guide the new practice of structural competency. The methods employ participant observation and interviews with program coordinators and participants in a social medicine course. Areas of success included: pedagogical innovation, conscientizing course participants, decentralising global health practice, and promoting reflexivity. Accompanying these successes were points of friction, including: inequities in personal risk and mobility limitations among course participants, as well as complexities and nuances in unintentionally reproducing hierarchies of knowledge. Specifically, further recommendations from our research include: (1) incorporating innovative pedagogical approaches, which highlight social medicine practices outside the global north, prioritising opportunities for cross-collaboration among practitioners from the global south; (2) framing social theory as a bidirectional flow: global south traditions must be included in teaching social theory; (3) practising structural humility by highlighting the perspectives and expertise of communities experiencing social and structural marginalisation, while including strategies in organising and direct pathways to political engagement. These conclusions highlight how social medicine-based training can both build from and move beyond the competencies explicitly specified by the structural competency model to create a global health practice inclusive of diverse thought from around the world.

KEYWORDS:

• Social medicine
• education
• global health
• structural competency
• conscientization

Background

Structural competency is a relatively new framework originating in the global north that trains health professionals to recognize how social structures shape the relationships between disease and its unequal distribution (Metzl & Roberts, 2014). Social structures can be defined as ‘the policies, economic systems, and other institutions that have produced and maintained social inequities and health disparities, often along the lines of social categories such as race, class, gender, and sexuality’ (Metzl & Hansen, 2014). As a similar but distinct field, social medicine is an approach to health that recognizes the centrality of the social and structural determination of health, integrates social theory to understand social forces that marginalise and harm communities, and builds collective power to challenge oppression and support the struggle for social justice. For over a century, social medicine scholars have proposed and argued that it is the nature of social circumstances, rather than biology, behaviour or a lack of technology, that produces and perpetuates health inequities (Oberlander et al., 2019). As the relatively new field of global health becomes cemented in the world of health sciences practice, research, and academia, the social medicine legacy has potential to guide teaching, practice, and research in global health (Adams et al., 2019; Holmes et al., 2014).

Global health is historically rooted in a logic of medical transnationalism, a practice that is more than two centuries old, and includes missionary, colonial and international health projects. Racism, ethnocentrism, economic disparity, and political hierarchies have created vast inequalities and health disparities in society. While medical professionals have been conscripted to rectify health disparities, they have also at times – unwittingly, or wittingly – reinforced them. Missionary physicians strove to save lives in order to save souls and convert (Redfield, 2013). Colonial medical practitioners sought to protect colonials’ health, but also the well-being of colonised labourers, thus ensuring the economic productivity of the imperialist enterprise (Packard, 2016; Vaughan, 1991). International health experts aimed to distribute health resources, but also set in motion neoliberal agendas that reproduced and cemented inequalities (Keshavjee, 2014).

Emerging at the turn of the twenty-first century, global health aspires to be a distinct enterprise from that of colonial and medicine and international health by striving for more equitable partnerships, including bilateral flows of ideas and personnel (Brown et al., 2006). However, the structure of global health, inherited from international health and colonial medicine institutions, does not predispose itself to this shift toward equity. Careful scrutiny of the underlying economic motives, patterns of immigration and authorship, premises of charity-based aid, and the questions left unanswered by randomised controlled trials, reveal that true equity and partnership in this field would require drastic structural changes.

Global health educational endeavours can also reproduce these oppressive, harmful dynamics. While purporting to build equity and challenge harmful social structures, they can reinforce the same marginalising forces they claim to be working against (Crane, 2013). Desiring to interrupt the harmful reproduction of social inequity that uncritical education can perpetuate, EqualHealth (formerly SocMed) created and implemented its first annual social medicine course in 2010 in Uganda. Since then, EqualHealth has offered annual courses, expanding it to new sites including Haiti in 2013 and Minnesota, U.S.A. in 2016. These courses aim to create transformative experiences by bringing learners together from the global north and the global south. The courses utilise critical pedagogy to attempt to disrupt the traditional donor-recipient relationships, to focus attention on the root causes of disease, and to create conditions for critical self-reflection on one’s role as a health worker committed to fighting oppression and reimagining healing. The course curriculum in Uganda, which is the focus of this study, was developed with input from community organisations including Inshuti Mu Buzima, TASO (The AIDS Service Organisation), St. Mary's Hospital Lacor and the Amuru Village Health Workers Association. The course is a fully immersive four week experience, with approximately 40 h of coursework per week. Course participants from multiple healthcare associated professions, including medicine, nursing, pharmacy, and psychology, as well as several continents, including North America, Africa, and Europe, are recruited to the course through an open application process. The call for application for prospective course participants is published on the organisation website; shared on social media platforms and amplified by course alumni; and shared on select professional community listservs. Students are selected for the course through a written application and interviews. Students are evaluated on class participation, a narrative medicine exercise, a final reflective essay, a group project in which a social medicine intervention is proposed and initiated on a topic of group consensus, and a final exam. The course is primarily (80%) financed through a sliding-scale course fee based on ability to pay. With this model, learners from the Global North subsidise the bulk of the course costs. A small amount of organisational fundraising (20%) covers the remaining costs. No learner, whether from the Global North or South, is ever turned away because of an inability to pay. Full scholarships are available to any learner with demonstrated need.

The courses have catalysed global interest in social medicine education and gave birth to the Social Medicine Consortium (SMC), a global network of institutions, individuals, and communities committed to using the social medicine lens to bring about social change that heals health inequities.

In this paper, we present salient themes related to the impact of the social medicine curriculum implemented by EqualHealth on students and describe unresolved tensions, as reported by course instructors and participants through semi-structured interviews and participant observation data. We close by considering the relationship between our curriculum and ongoing efforts at ‘structurally competent’ global health instruction.

Methods

As a team of authors, we draw from a diversity of national backgrounds–including Uganda, Zimbabwe, Nigeria, and the U.S.A. – as well as professional backgrounds – including medicine, nursing, and pharmacy – to perform an in-depth ethnographic exploration of social medicine education. This study employs qualitative research methods, specifically the anthropological technique of participant observation, accompanied by semi-structured, in-depth interviews. The interviews were audio-recorded. This methodology was deemed most appropriate for the exploration of the power dynamics of the practice of social medicine, and its impact on identities, capacity, and careers of people in the global north and global south. All authors were participants in or organisers of the social medicine course. The lead researcher assumed a course participant-researcher role in the 2020 Uganda course. As persons intimately familiar with this set of organisations, the authors were well positioned to evaluate the nuances of all aspects of participating in and executing this social medicine work.

Participant observation data was systematically collected from October 2019 to January 2020 in several capacities, including: video planning meetings for the Social Medicine course and an immersive one month Social Medicine course in Gulu, Uganda which involved travel to Rwinkwavu, Rwanda. For all participant observation data collection, field notes were recorded in a small field notebook in real time, and typed the subsequent evening or within two days. Memoing took place as field notes were produced. Memoing from field notes was used to guide and adjust semi-structured interview guides. In this way, preliminary theories from earlier interviews were tested and elaborated more fully in later interviews.

Tape-recorded, semi-structured, in-depth interviews were conducted throughout the social medicine course in Gulu, Uganda and Rwinkwavu, Rwanda. Study participants were recruited for interviews through opportunistic sampling. The researcher recruited study participants with a diversity of positionalities including course participants from various stages of training, course alumni, and course organisers (n = 19) (Table 1). The sample interview questions that guided the conversation with participants included:

1. How would you explain Social Medicine, how would you use these ideas in your work?

2. How did spending time with students from other countries influence the way you see yourself?

3. How do you see your organisation fitting into the larger field of global health?

4. In a scenario where you were not limited by funding opportunities, where you were not held accountable to the expectations of various funders, universities, or pressures to publish, where barriers to international travel were reduced for people in the global south, how would you want global health to look?

   Table 1. Interviewee characteristics.

   TOTAL	19
   ROLE:
   Staff	3(16%)
   Student	12 (63%)
   Alumni	4 (21%)
   COUNTRY OF ORIGIN
   U.S.A.	3 (16%)
   Uganda	9 (47%)
   Norway	1 (5%)
   Rwanda	2 (11%)
   Liberia	1 (5%)
   Zimbabwe	1 (5%)
   Nigeria	1 (5%)
   Tanzania	1 (5%)
   PROFESSIONAL BACKGROUND
   Medical student	7 (37%)
   Nurse	4 (22%)
   Physician	3 (16%)
   Pharmacist	1 (5%)
   Psychologist	1 (5%)
   Medical Illustrator	1 (5%)
   Dentist	1 (5%)
   Fellowship Administrator	1 (5%)
   GENDER
   Female	11 (58%)
   Male	8 (42%)
   AGE
   20–30	9 (47%)
   30–40	7 (37%)
   40–50	1 (5%)
   50–60	2 (11%)

Interview data was collected in private locations in one on one tape recorded interviews lasting from thirty minutes to one hour. Interviews were conducted until thematic saturation was achieved Table 2.

Table 2. Description of data sources.

Data source	Data Collection Tool	Period of data collection
Video planning meetings for the Social Medicine course	Participant Observation Specific attention to: power relations, delegation, and intentionality	Approximately seven hours over six video call sessions
In-person Social Medicine course in Gulu, Uganda which involved travel to Rwinkwavu, Rwanda.	Participant Observation Specific attention to: teaching, student-facilitator interaction, Global north/south students interaction	26 days of observation a typical class day stretched from 8:30 am – 5:00 pm
	Semi-Structured In-depth Interviews	26 days

Interviews were transcribed by two undergraduate research assistants. Interpretive thematic analysis guided the transcript coding and data analysis process (Huberman & Miles, 1994). Analysis of transcribed interview data and fieldwork notes was conducted with two research assistants and consisted of an iterative process of hand coding, categorization and noting of patterns, through cycles of increasing precision. Data with a single code were compiled and analysed for their characteristics and meanings, eventually guiding the thematic analysis of the data. The analysis process and emerging themes were cross-checked by three different scholars in the fields of medical anthropology and public health. Consensus regarding analysis was achieved through asynchronous virtual discussion of the analysis amongst all authors.

Results

Data analysis revealed six themes that characterised the social medicine curriculum. The themes include Pedagogy; Concienzitizing Course Participants; Decentralising Global Health; Reflexivity; Risk and Mobility; and Reproduction of Hierarchies of Knowledge. We consider these themes in tandem. These themes were selected based on recurrent concepts arising on data analysis, and are presented through representative quotations to highlight the direct experience of those involved in the course.

Pedagogy

The course organisers utilised specific pedagogical techniques, developed outside the global north, which powerfully represented abstract concepts, engendered discomfort, and ultimately raised consciousness in course participants.

Pedagogical principles and techniques developed by Paulo Freire and Augusto Boal, two Brazilian revolutionary scholars, were centred in the organisation’s works. Paulo Freire challenged educational conventions by engaging students in reflective action through a problem-posing model to incite political praxis (Caldas, 2020; Freire et al., 2014). Augusto Boal used his background in playwriting and directing to develop Theatre of the Oppressed (TOTO) to utilise performance as a way to dialogue and rehearse ideas of revolution (Caldas, 2020; Boal, 1985).

During the social medicine course, elements of theatre of the oppressed were utilised, including the principle of image theatre, to describe and explain the role of social structures in perpetuating health inequities globally. In this technique, a participant was asked to reflect on a theme discussed in the course, and without speaking, use the bodies of the other participants to ‘sculpt’ a scene portraying the idea, and later discuss with their colleagues the content of their script. Concepts represented included ‘colonialism’, ‘charity’, and ‘neoliberalism’.

Following the several constructions of human sculptures concretizing the concept of colonialism, one of the student participants from Sub-Saharan Africa noted: ‘After this I am asking myself, is there anything good about colonialism? Based on all the sculptures, it seems like no, so now I am asking myself this question’ (course participant 11). In response, another student participant reacted, ‘The purpose was to show it [colonialism], you didn’t have a chance to see it at that time, but it was like this, you think how it can change. … that was [it’s] … purpose’ (course participant 10). As indicated by some participants, the approach also evoked strong responses in participants, who expressed a level of discomfort along the lines of race and gender.

I do feel like the physical nature of things is something that, as a white man I have the least insight into. I feel like everybody that’s not a white man probably has some kind of visceral/ physical relationship to a lot of the concepts we were talking about (course participant 12).

Student participants also indicated how difficult it is to learn concepts that perpetuate social and structural inequities. Particularly, students expressed how they felt uncomfortable being associated with colonial practices. ‘We are not our ancestors’ (Course participant 17). Another participant reflected on their discussion of the topic following a sculpture activity.

Sometimes you feel like.. sometimes you are doing the sculpture, and someone was trying to say … how [person] used the students in Europe, and then the Black students. When you reflect upon that psychologically, to me I see someone who still has a mentality. Why would you want to use such a kind of thing, you are trying to make someone think that you are the colonial masters. That’s how I took it. You are the colonial masters, and we were like this. […] I think … learning … touching topics that are really sensitive … was a big challenge because it’s kinda traumatising, it creates shame … discomfort to people (course participant 8).

As indicated in the participants’ reactions, the image theatre approach elicited levels of discomfort, yet cultivated a dialogue that invited interrogation of the role of complex social forces such as race, gender, origin, and geography. The findings exemplifies a concrete ability to create and represent abstract concepts to allow for reimagined reality.

In the quest to challenge a problematic global health practice in which students, both local and international, often accept their surroundings without questioning, the social medicine course utilises a principle of ‘Walk the Talk’ to enable learners observe, question, and familiarise themselves with their new environment. Prior to these walks, participants are introduced to basic concepts in anthropology including the social construction of reality, biopower, social suffering, and unintended consequences. The walks then provide an opportunity to apply theory to their environment under the guidance of an instructor who is intimately familiar with the local context. Unique to the social medicine course, this technique was pioneered by Dr. Akiiki Bitabaleho of Rwanda University of Global Health Equity. She had this to share:

[Walk the Talk] came from frustration with international students who come for one week, it’s like a window into where we are, but not the whole picture. I began walking with the students to give them a more complete picture of Rwanda outside of the clinic settings. I never thought of it as a methodology […] originally this technique was for foreign students but now we do it for the Rwandan students. They are Rwandans, but they don’t have experience of the rural area. Seeing the agriculture, topography, seeing where patients walk was key.

She elaborated: ‘The key to social medicine is observation, so we wanted to have students see more, and reflect on what happens when they walk’.

Through this effort to turn careful attention to surroundings, students were asked to conceptualise the specific health implications for the individual, as well as the contributing social and structural factors rather than seeing inequalities as naturalised. In ‘Walk the Talk’ educators – the lead educator in this activity is usually one who has vast knowledge of the area – spent about 1-2 h walking with the students taking them through local markets, crossing roads, landmarks, up a hill, and nearby health centres among others. During one of these sessions, a student noted large piles of dirt at a distance. This prompted conversation about the local economy of the nearby town, which was largely based on the tungsten mining industry. One of the physician educators explained how the mining practices led to the local epidemic silicosis, and irreversible lung disease. This prompted further discussion on a resource extraction economy, elucidating how structural forces directly impact individual health outcomes.

Conscientising course participants

An implicit goal of the educational course, and explicit goal of the larger organisation is raising political consciousness. Consciousness can be defined in the critical, Latin American tradition as ‘an ability to intervene in reality in order to change it’ with implicit reference to class struggle and mental decolonization (Freire, 1973). This is not to say that the organisation and the course in particular assumed students were not politically aware before, but the course provides specific language, toolsets and space to engage with the struggle for health equity at a societal level. The organisation directs and organises this energy towards a confrontation of structural problems at local, national and international levels through one of its international programs, the Campaign Against Racism (CAR).

One of the study participants from Sub-Saharan Africa who is an alumnus of the course, but at the time of the interview was serving as a course facilitator, described an inspiration to act on structural determinants at a national level based on the principles and activities of the course, describing:

[…] when I was a medical student. Just a medical student. And there were issues around the country, doctors were not happy, junior and senior doctors went on strike. They were not happy, I was part of … leadership, … went to speak to national TV about the policies at the time […] So I think I take my pride because it was Social Medicine that empowered me, and through the network of Social Medicine it made it possible because [I] made a strategy plan for that movement … and for some reason it has always given me that boldness, that courage, that confidence to face whatever situation. Irrespective of looking at how small I could be, so it has opened so many new ways of thinking (Facilitator participant 1).

The participant described having applied the organising principles taught in the course to national politics, joining in with existing activism to advocate for better working conditions for physicians in Uganda. He explained that the medical student's efforts to speak on national TV were initiated by members of the 2015 social medicine course, supported by fund raising efforts from course classmates in the US. The overall efforts of this movement succeeded, resulting in legislation limiting shift hours. The social medicine approach allowed students to desegregate politics and health, using their authority as medical personnel to effect change. The act of solidarity exemplified by participants actions locally, coupled by the moral and financial support by their colleagues from the US, portrays the true nature of the local-global strategies to dismantle forces of oppression.

The achievements in consciousness-raising are also apparent at the international level. For example, the organisation’s program, CAR (Campaign Against Racism), has 13 chapters in 8 countries, providing the opportunity to act at the international level. In Haiti, Uganda, Zimbabwe, and Rwanda chapters of this campaign the founders were course alumni. Over the period of the immersive course, students already involved in the campaign used tactics taught – such as SMART goals and asset mapping – to collaboratively plan activities for their respective chapters in Uganda, Zimbabwe, Rwanda, Haiti, and Minnesota. The larger organisation approached political action from a structural lens: the chapters of this campaign agreed upon an organising statement specifically targeting racialized capitalism and neoliberalism as a source of health inequity. Actions included campaigning and calling on the World Bank and IMF to cancel all LMIC debt, advocating for abolition in the US, and lobbying for racism to be declared a public health crisis by city governments and universities.

This social medicine approach to global health partnership enabled a practice of consciousness raising among participants, allowing for connections to be made between global politics and health inequalities. Course students, alumni, and organisation members explicitly sought out political means of disrupting inequities on local and global scales. Pedagogical practices helped participants to reimagine their reality, teaching specific organising tools gave participants means to fight for these ideals, and the organisation’s structure provided a pathway for course graduates to join an international movement.

Decentralising global health

The activities of the consortium also sought to disrupt the typical flows of information in global health, where resources, knowledge, and legitimacy often flow from north to south. The SMC made efforts to create opportunities for knowledge sharing and production that specifically promoted collaboration between learners from different locations in the global south.

The activities of the course included several visits to rural clinics and villages, evoking drastically different responses in participants based on background and positionality. While students coming from the global north were made to question their place in rural settings, learners from other parts of the global south found direct applicability from these activities. A nurse course participant from Sub-Saharan Africa, who works as a supervisor for community health workers in outreach to remote villages, found such visits productive. Visiting community health clinics allowed comparison and collaboration between supervisors of community health workers on such topics as the content and regularity of training for community health workers, defining scope of practice for these workers, and supervision structures. In accompanying the community health workers to a family home, the participant elaborated:

So, visiting the family in their homes in the community, I just—it was just a repeated experience for me. As I told you earlier I’m always doing community work,[…] I value it so much, yes, because I always want to be with the poor people..[..]Yeah, so it was a good experience for me. I was just happy to go and see how it is on that side, apart from my country, I was fortunate to see the villages in Uganda (course participant 14).

The opportunity for comparison across resource limited settings allowed for collaboration and knowledge co-production, for these practitioners. This decentralised not only northern knowledge hierarchies, but also hierarchies within the health profession: nurses and community health workers led these conversations, and physicians were put in the position of trying to understand how these conversations fit into their practice, rather than the reverse.

Reflexivity

In creating an immersive social medicine course with geographically and professionally diverse participants, the organisation succeeded in creating space and process for reflexivity. Reflexivity can be understood as a culmination of self understanding, dialogue with peers, and insights-to-action (Liwanag & Rhule, 2021). The curriculum of the course strove to make formal space for reflexivity through activities such as a privilege/assets walk, asking all participants to share a story of self, and periodically holding space for debriefing after tense moments. When asked about reflection in an interview, a course instructor shared her own process in making sense of these complex relationships, reading a poem she had written after a group reflection session:

Who are you?

I see you, but who are you?

Who formed you?

[…]

What trauma did you, your people, your type, your color, your education, your trade, your country, your continent, your age, your gender, your history, your geography, your language, your understanding, your sexual orientation, what trauma?

[…]

For all this and that is unknown partially or partially known, I need your forgiveness. And I need to forgive you. So as to create a garden where we can plant new seeds, grow new plants, see new blooms, weed out, collect harvest and allow creativity to continue so that we are co-creators with God … that is how I debriefed (course instructor 5).

In her poem, this educator makes clear the magnitude of the struggle she faces in reconciling the concept of partnership in the context of such deep differences and disconnect. She imagines how the other might see her and describes her own limitations in seeing the other. In acknowledging the vastness of this disconnect, she can begin to honestly express the amount of work needed to reach a genuinely productive relationship. Ultimately, she retains faith that co-creation across these differences is a worthy objective.

Risk and mobility

While the SMC made efforts to decentralise global health practice as described above, the organisation still faced structural limitations in disrupting the longstanding problem of unidirectional flow of global health learners from HIC to LMIC (Eichbaum et al., 2020; Rohrbaugh et al., 2016). The levels of risk and potential reward undertaken by students travelling from other LMIC remained relatively greater than that of their colleagues coming from the US, Canada, or Norway.

Students coming to take the immersive course from the US, Canada, or Norway frequently framed the experience as a way to travel or as a vacation destination. These students described little difficulty in obtaining plane tickets, vaccinations, or visas to Uganda and Rwanda. These expenses were often covered by their universities, and many students spent time before or after attending safaris or otherwise exploring.

For some students coming from other places in the global south, the sacrifice of attending was far higher. During the period of the immersive social medicine course, political and economic tensions between Uganda and Rwanda were particularly high. Crossing the border on land had become impossible, but travel by air via an intermediate destination allowed for safe crossing. The organisation sponsored one student and two educators from Rwanda to fly in via this circuitous pattern. The student from Rwanda describes his experience landing in Uganda:

Fear. From Rwanda to Uganda, you cannot cross the border easily … I felt a lot of fear coming to the class. Some of my family understands, but whether they accept or not, I have to come. It is better to die doing something that can help your society, than just staying at home thinking (course participant 10).

This quote indicates that the risk is larger, but also underlines the desire for and relative gain from attending such a course.

One participant from another country in Sub-Saharan Africa similarly described assuming a high level of risk to attend the immersive course:

[…]my Human Resources was a different story. She didn’t think it was important for me to do it now, you know. And she was, she was actually saying ‘you can just cancel it now and you can just go next year.’And I was like, no, I can’t wait for next year … yeah. And they couldn’t give me off days—even if I take off days for that thing, they could not give me. And they told me like, “if you go we’ll dismiss you”. And I figured—you know what, these guys aren’t going to help me, and I don’t think I want to miss it (course participant 19).

This participant risked their employment in order to come to the course. Again, while this level of risk was higher, the potential benefit was also larger. Based on connections made over the educational course, they were able to obtain a scholarship to pursue postgraduate studies in the global health equity domain.

The opportunities created by these NGOs, while striving towards an equitable practice, were severely limited by geopolitical power dynamics beyond their control. In creating opportunities to expose these large scale inequities by teaching historical context and advocating for structural change, some of these very power dynamics were inescapably reproduced at the individual level, and went unacknowledged. Race and nationality continued to dictate mobility, and the legitimacy associated with interacting with an American NGO led global south participants to accept the possibility of damage to livelihood, or even bodily harm. The decision to assume this higher level of risk was in some cases rational, affording important opportunities for career advancement.

Reproduction of hierarchies of knowledge

As described above, the organisations made significant efforts to place value on health and healing knowledge produced outside the US as defining elements of Social Medicine. Yet the organisers of the immersive course still felt pressure to include elements of social theory produced in the US and Europe in the curriculum to make graduates legitimate in an international context. As biomedical practices in global health often involve the flow of technology from north to south; social medicine similarly must contend with the flow of ideas from north to south as a product of structural racism in the academic social sciences.

In the immersive course, a lesson was taught on social theory. This included concepts credited to Robert K Merton, Thomas Luckman, Peter Berger, and Michel Foucault: all U.S.A. and European social scientists. At the outset of the lecture, the educator explained that one of the reasons to teach these theories: ‘It also gives us “street credibility” (use of air quotes here) or legitimacy as a scientific field’. The idea of credibility as defined by that coming from northern centres of production, is a structural challenge difficult for the organisations to overcome in its attempts to establish social medicine as a rigorous practice.

Reactions to this set of ideas were varied among participants from different locations, not divided equally based on country of origin. One course alumni from Nigeria returned to Uganda the following year to assist in teaching the segment of the course on social theory. He described his reaction the theory portion of the course as conflicted:

I do feel disadvantaged. Just like me, I think the average African scholar who would be very sincere to themselves would tell you that they feel disadvantaged but I also think this should be a motivation for us to do something. When I was reading and preparing to teach, I felt like I should write about this feeling but also felt like I should collaborate, I should also write, you know I should teach people about the social theories of health. So right now I am so challenged than ever to become a teacher in medical sociology, and I'm just … even if it is something like write a book, and make sure my book is used as a teaching material. It is great that I feel disadvantaged, because feeling disadvantaged makes me want to do something. […] and I think anybody who is like me um, we are done crying about how the Americans and the Europeans are ahead of us. We can’t do anything about it. We can’t do anything about them being more exposed. What we can do is try to make sure that we are matching up. So yeah, I was very challenged, very challenged. An example is like reading Foucault? F- Foucault? Who is that guy! I had no idea, no idea! [laughing] I have never felt so stupid in my life! So, how am I going to read this whole book when I took so much time to comprehend two pages but I want to be able to comprehend it. So, maybe it might be a longer road for me, yeah. But I am walking the road. Yes. I want to be Kleinman someday. Yeah. I already told you about my love for medical anthropology (course participant 2).

This participant’s experience captures many of the frictions in this social medicine approach to global health. While he describes the ways in which social theory texts from the US and Europe made him feel ‘behind’ or ‘disadvantaged’, he doesn’t see this as disempowering, but instead motivating. The exposure to sociology and anthropology concepts was inspiring and influential on his career direction. While this quote exemplifies the reproduction of knowledge hierarchies, it also alludes to the possibility of broadening the social science conversation to include more voices from outside the US and Europe, allowing people to prove themselves on whatever stage they want.

Discussion

Global health is a direct descendent of international and colonial health projects. In global health education, institutional partnerships carry forward these power dynamics. In response, a call for the incorporation of structural competency principles into the practice of global health has arisen, however, few examples of the application of these principles exist in practice to this date (Finnegan et al., 2018; Harvey et al., 2022; Van Wieren et al., 2014). The work of the Social Medicine Consortium provides an example of the ways in which the preexisting field of social medicine may provide practical guidance in the application of structural competency principles to global health education and organising. While the work of the SMC presents a radical shift in attitude and praxis from standard practices in global health, the challenges faced by the organisation underscore the structural problems limiting a structurally competent global health practice.

In 2020, Harvey et al. described a specific set of ‘structural competency sub-competencies’ to guide the field of global health education. Here we will describe how the six themes described above relate to the sub-competencies elucidated by Harvey et al. (2022). These sub-competencies include: (1) Describing the role of social structures in producing and maintaining health inequities globally, (2) Identifying the ways that structural inequalities are naturalised within the field of global health, (3) Discussing the impact of structures on the practice of global health, (4) Recognising structural interventions for addressing global health inequities, and (5) Applying the concept of structural humility in the context of global health.

Describing the role of social structures

The work of the SMC emphasises the importance of a carefully cultivated pedagogical approach in international educational partnerships, and it successfully provides practical tools for the implementation of structural competency principles. The pedagogical approach utilised in the social medicine course allowed participants to enact and embody abstract concepts of social structures, meeting the structural competency of ‘Describing the role of social structures in producing and maintaining health inequities globally’ (Harvey et al., 2022). This approach, utilising techniques adapted from Brazilian revolutionary thinkers – including the theatre of the oppressed – engendered discomfort for students both from the global north and south. The consequences for some students from LMIC included revelations around the far reaching, modern, destructive impacts of colonialism, often bringing forward strong emotional reactions, even anger. As described by Freire, these emotional and experiential moments are key to the process of conscientization (Freire et al., 2014). They alter consciousness at the intrapersonal level about one’s position in relationship to power. On behalf of students participating in these activities from the HIC, any discomfort experienced could also be considered part of a conscientizing practice. Genuine solidarity is an unsettled matter that cannot easily reconcile present grievances (Tuck & Yang, 2012). Of note, both the Freire and Boal techniques were developed and utilised originally specifically with groups of people who identified as oppressed. Applying these methods with a group of health workers – who certainly may be oppressed along certain lines of identity but often aren't considered oppressed as a general group – may have its limitations.

Identifying the ways that structural inequalities are naturalised in global health

Educational practices involving community walks allowed for connections to be made between abstract concepts, the physical environment, and the impact on an individual’s health, forcing students to question that which may have previously been considered natural, and instead name the role of structural forces in their everyday surroundings. Thereby, the ‘Walk the Talk’ technique could be used as a means of achieving the structural competency sub-competency of ‘Identifying the ways that structural inequalities are naturalised within the field of global health’ (Harvey et al., 2022). This approach goes beyond the calls for cultural competency and cultural humility in global health education, instead providing a mechanism to engage with structures of oppression from the intra- and interpersonal, to the global level (Ablah et al., 2014).

Recognising structural interventions for addressing global health inequities

The activities of the SMC took on an explicitly political tone. By giving participants the tools for community and international organising, including the international Campaign Against Racism, the SMC directed its energy towards a confrontation of structural problems at the local, national, and international levels. In this way, social medicine practically taught students to recognize and intervene at the structural level by enacting global health as a political project, providing concrete examples of means of meeting the structural competency sub-competency of ‘Recognising structural interventions for addressing global health inequities’ (Harvey et al., 2022).

Discussing the impact of structures on the practice of global health

The efforts to centre the needs and work of practitioners outside of the global north in the immersive course represents another key element of the social medicine approach that can guide structural competency work. By facilitating exchanges for practitioners between LMIC, knowledge produced outside HIC is legitimising and valued as a key part of medical transnationalism. This approach provided learning opportunities that decentered US physicians, paving the path for other interprofessional and international collaborations, thereby establishing an example of a means to not only accomplish the structural competency sub-competency of ‘Discuss[ing] the impact of structures on the practice of global health’, but to also provide a model for disrupting some of these harmful structures (Harvey et al., 2022).

Applying the concept of structural humility in global health

Through promoting a practice of reflexivity, participants in the immersive course were made to confront their own challenges to partnership through what can be understood as structural humility. So often in global health work, the material inequalities that form a striking contrast between research staff, local and foreign scientists, and institutions are not openly discussed, though they certainly play into mutual perceptions. As Wenzel Geissler describes: ‘conversations about colonialism among local staff at times substitute open debates about contemporary inequalities’ (Geissler, 2013). Actively unknowing and ignoring these inequalities may serve the productive function of allowing medical personnel from different backgrounds to work together. However, in this state of unknowing, these injustices are cast as beyond the scope of scientists and health practitioners and as simply unchangeable. The social medicine approach sought to make evident the role of not only histories of colonialism, but also the present geopolitical forces and modern economic practices in creating current health inequities. Beyond discussing these macro elements, the course organisers were able to foster reflection at the interpersonal level between participants from different backgrounds. However, it was likely the resulting intrapersonal work that was most important. This level of honesty and metacognition brought tensions to the fore, at times making relationships between diverse participants more difficult. However, it is precisely the ability to steer into this discomfort that makes this approach strong. The organisation seeks not only to disrupt structural inequities in global health through political action, but to begin to unpack the obstacles to partnership at the intra and interpersonal level thereby approaching the structural competency sub-competency of ‘Applying the concept of structural humility in the context of global health’ (Harvey et al., 2022). Global South scholars have pointed out that both structural competency, and structural humility in particular, as frameworks developed in the global north, require further inquiry by scholars from the global south to make the concepts applicable to LMIC practitioners.

Points of further growth

While the social medicine approach provides a productive model for incorporating structural competency principles into global health education and in many ways, a number of points of growth remain. These largely reflect the structural barriers to genuine partnership and paradigm shift.

Among these barriers, the SMC faced structural limitations in disrupting the longstanding problem of unidirectional flow of global health learners from HIC to LMIC. Despite being part of a relatively elite social class, medical students and personnel from the global south faced limitations in their ability to travel. Limitations in mobility are a well-documented phenomenon and source of inequity in global health partnerships (Crane, 2013; Massey, 2009; Mbembe et al., 2019). The theory of sedentarist metaphysics stipulates that black and brown bodies in the Global.

South are expected to remain in place, allowing mobile northern students to travel and capitalise on the educational opportunities presented by high rates of disease in these populations, with the trope of helping those in the global south (Crane, 2013). The organisation sought to push back on these dynamics, as described above, but were unable to entirely dispel oppression perpetuated by racialized global economic and political structures which limit the mobility of LMIC practitioners.

While the social medicine approach attempted to disband concepts of ‘white saviour complex’ and the idea that learners from HIC were ‘helping’ those in LMIC, it can be argued that the presence of visitors from HIC inevitably stretches already sparse resources (Eichbaum et al., 2020). Additionally, the ease of travel in terms of expense and obtaining visas for students coming from HIC as well as the sense of adventure or vacation, contrasts sharply with the risks taken by some of the learners from other LMIC (Mbembe et al., 2019). Risking employment or bodily safety to attend the Uganda course, indicates that these LMIC learners saw the immersive course not as a vacation, but as a vital opportunity. This insinuates that the potential rewards from attending is greater for students from other LMIC, pointing to the imbalance of educational opportunity, and at times, inescapable trope that knowledge and resources flow from the HIC to LMIC.

Other points of friction in the social medicine approach included assumptions that social theory from scholars in HIC was necessary to legitimate the title of social medicine. This assumption is ambiguous. On one hand, the idea that practitioners from LMIC countries need an understanding of theory – often written in a second, third or fourth language for these practitioners – to practise a form of medicine informed by the social, may exclude some from the conversation, and undo the work in decentering knowledge from the HIC. On the other hand, excluding learners from LMIC from sociology and anthropology conversations would be counterproductive: making these ideas accessible to a wider, more diverse audience could be framed as a means of democratising these academic concepts. This tension points to the larger problem of white supremacist logics forming the basis of these academic fields. The utility of teaching this theory remains a source of debate and ambiguity among those in the organisation, as the definition of social medicine continues to shift. Perhaps future iterations of this social medicine cannon can move to include more theorists from the global south such as Jaime Breilh, Franz Fanon, Achille Mbembe, Asa Cristina Laurel, and Olivia Lopez Arellano.

The Social Medicine Consortium made significant efforts to engender mental, conceptual, and structural resistance to hierarchies perpetuating colonial and neocolonial logics in transnational medical partnerships and practice, serving as a model for the new field of structural competency. The SMC’s practices demonstrate the potential for a paradigm shift in the culture of global health: uplifting existing local knowledge, promoting reflexivity, focusing on conscientizing pedagogy and political activation of health care providers.

Future recommendations

This research points to ways in which social medicine-based training and organising can both operationalize and move beyond the competencies explicitly specified by the structural competency model. Specifically, further recommendations from our research include the following:

1. Global health education must incorporate pedagogical approaches which highlight and foreground ongoing social medicine practices outside the global north, prioritising opportunities for cross-collaboration among practitioners from diverse LMIC.

The study demonstrates the richness afforded by and the challenges of executing an educational experience for a diverse cohort of students from LMIC and HIC countries. Utilising an innovative pedagogical approach, such as elements from TOTO, which force intra and interpersonal reflections about one’s position in relationship to power, enables students to conceptualise and reimagine the underlying structures creating health inequities. Opportunities for cross-collaboration among practitioners from diverse LMIC should be prioritised, therefore educational activities related to global health should be held in locations most easily accessible to practitioners from LMIC. Simultaneously, inequities in mobility for global health professionals from LMIC must be acknowledged and contextualised within a racialized global system.

1. Social theory must be framed as a bidirectional flow in Global health education.

Incorporating social theory – particularly that generated in North America and Europe – into global health education may provide useful framing and the potential to broaden conversations in social science fields to include more voices. Simultaneously, the production of theory should be framed as a bidirectional flow: social medicine traditions developed in the Global South – including the Latin American practice, Indian traditions, and practices originating in Africa, must be included in teaching social theory.

1. Global health education must emphasise structural humility by highlighting the perspectives and expertise of communities experiencing social and structural marginalisation, while including strategies in organising and direct pathways to political engagement.

Promoting reflexivity and awareness among all participants in transnational medical education and coalition building is a key process. This should include inherent discomfort in reconciling the challenges to partnership, with an emphasis on uplifting the expertise of the communities that practitioners aim to serve. Global health inequities should be contextualised, according to the principles of social medicine, as a product of historical circumstances as well as modern economic and political policies. Strategies in community, national, and international organising, as well as direct pathways to political engagement should be considered a part of global health education.

Conclusion

Social medicine is a long-standing framework for understanding inequitable burdens of disease around the world, and can serve as a model for the newer trend of incorporating the principles of structural competency into global health educational models. Based on this study of a specific social medicine course, we found that the practices in the course met the structural competency sub competencies outlined in the existing literature. However, the findings suggested that global health education must go beyond these sub competencies to incorporate rich traditions originating from the global south in order to create a global health that is inclusive and robust.

Acknowledgements

We would like to thank Sophie Zhang and Francesca MacLaren for their assistance in transcription. Thank you to Drs. Seth M. Holmes, Vinncanne Adams, Ndola Prata, and Colette Auerswald for making this work possible.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was approved by the University of California San Francisco, University of California Berkeley Joint Medical Program Thesis Grant under the CPHS Protocol Number 2019-04-12105.