July 2022

July 2022 Blog: Decolonisation and Diversification of Medical Education

Background and Definition

Decolonisation speaks primarily to racial discrimination, both historical and current, in the curriculum and the community. More broadly, decolonisation has often been intertwined with the concept of an inclusive curriculum - i.e. the curriculum, its delivery and experience that works for all. With particular reference to the curriculum, decolonisation aims to move towards an inclusive, globally aware and culturally aware curriculum.

While academic decolonisation is more focused on the curriculum, knowledge and research approaches, “diversification” (or “inclusivity”) is focused on diversifying the student and staff populations. Both decolonisation and diversification are necessary to produce long-term change in the institution. Simply, there is little point in diversifying student intake if we train all students to think as white, middle-class males of the majority nationality. We must find a variety of ways universities, departments and medical education can support diversity and inclusivity.

Decolonisation in medical education requires a philosophical and epistemological rebalancing, that seeks to reset our world view to include a more diverse, inclusive and global range of viewpoints. This means that to truly decolonise the curriculum we will likely not change the fundamentals but how we teach them, the sources we draw upon to teach them, and the contexts / lenses we consider them through will evolve. As educators we need to become more conscious of the global, cultural, ethical and historical contexts of our knowledge and teaching.

Positionality and Transitionality

Positionality is the concept that all knowledge has a geopolitical and historical location, there is no monocultural or universally valid way to view knowledge (“knowledge doesn’t happen in a vacuum”). When applied to medical education, knowledge in a decolonised curriculum should be positioned in the context in which it was discovered and has been used. This avoids the assumption that knowledge is situated in an abstract position of universality and objectivity with no geopolitical or historical grounding, the domain of “the unmarked scholar” i.e. uncontextualized knowledge which undermines the work of diverse educational researchers. By “positioning” knowledge, it opens discussions of the ethical use of knowledge and leads on to the concept of transitionality i.e. what is the purpose of knowledge and what are the applications of that knowledge?

An example of the need for positionality and transitionality would be the diagnosis of COVID-19. When considered purely from a more economically developed countries (MEDC) perspective, RT-PCR is an ideal technique. Its positionality places its development and use firmly in MEDCs. However, to assume that RT-PCR is universally applicable denies its positionality because RT-PCR as a diagnostic technique is not widely available in areas with poor medical infrastructure. This failure to take a more globally inclusive view led to a growing health inequality in COVID-19 diagnoses. Therefore, a more global view when considering positionality and transitionality, is vital for developing globally inclusive solutions. This means stepping back and asking, “What are the implications and applications of this knowledge for diverse groups?”

This is the call of decolonisation for medical education. By using the concept of positionality, we should see medical education as a rich and diverse endeavour in which everyone can play a part. This will involve digging into the literature to correct misattributions and appropriations, teaching those corrections, engaging with injustices and building a framework to be more inclusive. Therefore, we must not only engage with the positionality of medical education but also consider our own positionality when teaching and researching.

Decolonising Institutional Power and Relationality

Decolonisation sees the role of the institution and the curriculum not only as a system for transferring knowledge, but as a system for empowering students, staff and the community. A curriculum that aims to both teach, and empower, highlights excellent contemporary research, while embracing the diversity of those carrying it out or questioning the lack of diversity. This is not an argument for identity politics, it is an argument for fair attribution to all scholars, educators and communities. Unfortunately, current silence on the matter only empowers the inequalities embedded in institutions.

Moving away from the taught curriculum, the decolonisation agenda questions the relationships and power-dynamics between teacher and student i.e. the relationality. Put simply, how does the teaching approach influence students? Are there certain approaches that favour certain groups? If students do not have a voice in curriculum design, is a valuable dialogue lost, and an unwanted power-dynamic formed? Does this unidirectional flow signal that the thoughts, values and cultures of students do not matter?

Ultimately, it can be hard to answer the questions of relationality pragmatically, balancing both student voice/choice, with academic time and resources. However, the impetus for change is pressing, and institutions must rise to the challenge to become more socially and globally inclusive. This agenda should dovetail with diversity and inclusivity strategies, to provide diverse students with a global and diverse curriculum.

Prof Olanrewaju Sorinola
Professor of Medical Education
University of Warwick, UK