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Inclusion, access and social justice: the rhizomic evolution of a field across a continent
  1. Carla Tsampiras1,
  2. Nolwazi Mkhwanazi2,
  3. Victoria Hume2,3
  1. 1 Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
  2. 2 WiSER, University of the Witwatersrand, Johannesburg, South Africa
  3. 3 The Culture, Health and Wellbeing Alliance, UK
  1. Correspondence to Dr Carla Tsampiras, Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa; carla.tsampiras{at}uct.ac.za

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Wamkelekile, karibu, welkom, and welcome to this special issue of the journal titled ‘Medical and Health Humanities in Africa – Inclusion, Access and Social Justice’. Medical and Health Humanities (MHH) is a nascent field on the African continent; while the research, teaching, and practices of many people can be categorised as being MHH, it is only in the last six years that practitioners have initiated formal networks, convened conferences, and applied for funding to explore the particular form and experiences of MHH in parts of Africa. As researchers, lecturers and practitioners of MHH based in South Africa, we have an interest in finding out if, and how, MHH is unfolding in other countries on the continent. The special issue is thus born from two desires. The first is to seek and strengthen networks continentally and internationally, and the second is to explore understandings, practices, and perceptions of MHH in other African countries.

Since 2013, universities in South Africa have held conferences and workshops dedicated to exploring how interdisciplinary work across humanities, social sciences, arts and health sciences can change understandings of health, healing and well-being. At present, however, only the University of the Witwatersrand has a formal research programme in Medical Humanities located at the Wits Institute for Social and Economic Research (WiSER), while the University of Cape Town has an online MHH programme, MHH projects and MHH-linked undergraduate curricula. Other universities in the country, such as the University of Stellenbosch, have MHH-inspired projects. Beyond the tip of the continent, the University of Ibadan in Nigeria has, since 2016, been formalising the establishment of an Institute of Bioethics and Medical Humanities, while the Suez Canal University in Egypt unveiled plans to incorporate humanities in medical education in the same year.1

In South Africa, the first two MHH conferences were held at the University of the Witwatersrand. The first conference ‘Body Knowledge: Medicine and the Humanities in Conversation’ took place in September 2013, and the second conference, ‘Age and the Body: Cultures and Conversations’, took place in June 2014. The third conference, ‘Medical Humanities in Africa’, was organised by the University of Cape Town in August 2014. It focused on four themes—paradigms, pedagogy, practice and potential. To our knowledge, the first conference outside of South Africa was held in Zomba, Malawi, in August 2017 and its focus was the development of the field in Africa. The 200 delegates who attended it discussed questions similar to those explored elsewhere (How is medical humanities defined? What is its purpose?) alongside other questions linked specifically to understanding the relationship between the field and the continent (What is the relationship between MHH in ‘the north’ and ‘the south’? Is it possible to speak of a pan-African MHH? How might knowledge and other hierarchies shape the formation of the field?) These debates are ongoing, but reveal a growing energy for, and interest in, MHH. The conference also presented a platform for practitioners to discuss their work. South African and Malawian colleagues are currently discussing a second conference of ‘Medical Humanities in Africa’ in Malawi in mid-2019.

In addition to the larger conference spaces, two MHH interest groups have been formed. The Health Professions Education Group (HPEG) and the Health Humanities Interest Group (HHIG). The HPEG obtained support from the Brocher Foundation to run a workshop in Geneva in 2016. This workshop brought together educators from Africa, Europe and North America. The HHIG is a smaller ‘in-house’ group specifically constituted ‘to stimulate conversation and thoughts around health humanities’ on the health sciences campus at Stellenbosch University.2

Despite the absence of formal MHH spaces within most African universities, many academics, activists, artists, medical practitioners and health professionals have already been working across and between disciplines and boundaries in ways that, elsewhere, might easily be identified as MHH. Many of us who are cultivating the field occupy ‘edgelands’ between epistemic, pedagogical, disciplinary, physical, administrative, and financial spaces. Our efforts at introducing or growing MHH reflect the same ‘edgelands’ ascribed to medical humanities and research methodologies by Rapport et al in this journal in 2004 and 2005.3 4 Drawing from a description initially used in discussions of the built environment, Rapport et al noted that the edgeland—a term conventionally associated with the interesting, slightly disturbing space on the outskirts between rural and urban areas—could serve as a useful metaphor for the space occupied by medical humanities as a field, and those working in it. Observing that while few may choose the discomfort of living in the edgelands, ‘… the dynamic of life in these areas, the tensions, frictions, and loneliness of life at the margins, can generate creativity and innovation’ (Rapport et al, p6).3

The metaphor of edgelands, and what they may generate, resonates to some degree with conversations, gatherings, practices and observations linked to the emergence of MHH and discussed by some of the contributors in this edition. Praxis and pedagogy have been tinged by the complex dynamics of life, discomfort, creativity and innovation described by Rapport et al, alongside the realities of inequalities and social injustices. However, in tracking a history, or perhaps more appropriately, tracing some strands of the evolution of MHH in certain parts of Africa, there is a need to deliberately mix metaphors and slip beneath the surface to consider rhizomic networks that connect different edgelands and the multiple histories and experiences of what we are now calling MHH.

In so doing, what is revealed is how the loneliness of life at the margins is eased when there are connections between different margins. Central to mapping the evolutions of MHH in parts of Africa is recognising that these are not neatly linear or chronological but, to draw lightly on Deleuze and Guattari, more like a rhizome which ‘connects any point to any other point’, is composed of ‘dimensions or rather directions in motion’ and has ‘neither beginning nor end, but always a middle (milieu) from which it grows and which it overspills’.5 It is a ‘multiplicity’ undergoing metamorphosis and constantly changing (Deleuze and Guattari, p21).5 ‘A rhizome’, they continue, ‘is made of plateaus’ which they describe as ‘any multiplicity connected to other multiplicities by superficial underground stems in such a way as to form or extend a rhizome’ (pp21–22). There are a series of plateaus that connect to different MHH rhizomes, which in turn form and connect with each other. These rhizomes are linked to places, spaces, disciplines, practices, and professional and personal identities. This special issue grows from and extends the MHH rhizomes, it presents a series of plateaus formed by the contributors, and concerned with practice, research, education, and critical reflection.

Each contributor to this special issue, and each ‘home’ discipline or practice from which they grew and connected, is able to trace their own rhizomes in the field that may link back to formal efforts or serendipitous connection. While we have written a chronology that traces the evolution of what those involved identify as MHH, we are conscious of those who came before us who may not necessarily have self-identified their work as being part of the field. The three of us come from disciplinary and practice backgrounds that have complex histories in relation to health, humanities, and arts, and these do not neatly overlap to form united, uninterrupted chronologies—the interactions have been far more organic and cyclical.

This special issue and blog brings together established academics who have been central to the evolution of the field in Africa; postgraduates or mid-career academics shaping the future of the field; as well as practitioners or facilitators of the arts or health sciences. Some of our contributors embrace MHH as an identity, others retain their disciplinary or practice identities and enjoy seeing how the field of MHH might change and morph those identities. Still others do not necessarily feel the need to commit themselves to one thing or another and are content doing what they have always done—being slightly at odds with hegemonic expectations. For some, MHH has provided a name for something they had already been doing, while others have been able to imagine doing new things under this banner. We acknowledge all who have shaped what we now call MHH and those who continue to shape the journeys of the contributors. We would like to remember specifically Claire Penn who died before completing her article for the special issue—her contributions, on multiple levels, to interdisciplinary work will not be forgotten.

As guest editors, we are conscious of the existing hierarchies and power dynamics prevalent between institutions in countries and across regions of the continent; between established and emerging researchers; and between academics and practitioners. These hierarchies extend to hierarchies of knowledge, language, economic privilege, and digital access to academic sources. While not all of these could be addressed, in a spirit of epistemic generosity, collaborative engagement and reflexive practice, in putting together the special issue we took decisions to pool resources and create critical but caring spaces where contributors could come together to share their work and learn from each other. This involved actively encouraging new and emerging academics, hosting a workshop where contributors received and gave feedback on work, and a commitment to working with previously unpublished contributors. Initial submissions to the workshop and journal came from researchers and practitioners working on, or based in, South Africa, Tanzania, Nigeria, Kenya, Malawi, Zimbabwe and the UK. The workshop thus also served the purpose of facilitating the growth of the MHH in Africa network so that it extended beyond Southern Africa.

After the call for papers we received abstracts for full-length articles, commentary pieces, poetry and photographic exhibitions from historians, anthropologists, psychologists, health science practitioners, creative artists, musicians, poets, educators and trainers. While not all the submissions have made it into this special issue, additional contributions have found a place alongside it in the BMJ MH’s blog. The process of submission and participation in the workshop, as well as the expansion of the special issue into the blog, has allowed for connections, multiplicities and the formation and extension of rhizomes of knowledge and practice that spread beyond the written page.

The contributions are connected by their engagement with issues linked to access, inclusion, and social justice at every level from individual to social via the personal, professional, systemic and social. Sadock, Mulemi and Hume’s work brings into conversation their varying attempts to access health spaces and negotiate differing degrees of epistemic sensitivity. In their two commentary pieces, Pentecost, a biomedical doctor and anthropologist, and van der Wiel, an anthropologist working among clinicians, reflect on their experiences and discuss, respectively, the ethics of transdisciplinarity and the need for methodological clarity. Leslie Swartz, who has long worked beyond and between disciplinary strictures, calls for engagement with, and subversion of, dominant forms of representations of critical disability studies to facilitate more inclusive conversations in the area and between regions. Wainwright and Hume, whose journeys in the field of MHH have positioned them in various locations (in place and time), reflect on the development of the field in different contexts and critically engage with the concept of ‘global’ medical humanities.

At the time of writing, a meeting on ‘hierarchies in health sciences’ has just been held at the University of Cape Town’s health sciences faculty. Students from health and rehabilitation sciences reported on experiences of discrimination and differential treatment between themselves and students of medicine and suggested ways to address these hierarchies of privilege. Since the #FMF (#FeesMustFall) protests, in which students demanded free tertiary education and transformation within universities across South Africa, discussions about curriculum review and change, across disciplines and faculties, have been of central concern to universities. Considering MHH and education as one ‘direction in motion’, the research articles in the special issue outlining ideas for the field, experiences in the current contexts and arguments for the exploration of specific disciplinary contributions to knowledge are prescient. Gerber et al argue for a ‘critical orientation’ towards the inclusion of humanities in health sciences curricula in South Africa. This cohort of authors have been central in establishing a special interest group on humanities and health sciences education and interrogating the relationship between health sciences and humanities in terms of higher education praxis. In her article, Tsampiras provides an overview of MHH and health sciences education interventions at one university while identifying the links between hierarchies, histories, and social injustices that have shaped access to, inclusion in, and the physical and philosophical location of, higher education.

Moving from education, as one plateau, four articles in the special issue engage with another—research. As historians who have long worked in collaborative and participatory ways on various health concerns, the article by Parle, Hodes and Waetjen, draws on three different pharmaceutical products, over three different time periods, to reveal the significant contributions historians can make to understandings of pharmacopolitics. The article by Alison Swartz et al is an example of MHH research praxis linked directly to a health concern framed by social injustices. In examining childhood poisoning linked to the use of rodenticides, the authors discuss not only their findings but also the challenges and successes of undertaking interdisciplinary work in a team composed of medical and social anthropologists, a fine artist and environmental health specialists.

Masuku et al take interdisciplinary praxis further by moving beyond the laboratory and ivory tower to participatory community engagement projects. Their article reports on a collaborative engagement between academics, artists and young people linked to explorations of tuberculosis. Staying with interdisciplinary praxis that incorporates creativity, the article by Treffry-Goatley et al details how digital storytelling can be used to promote ARV (antiretrovirals) adherence. Both of these articles reveal the potential of creative, engaged, inclusive responses to health concerns. Other creative, engaged, imaginative and exciting examples of ways of understanding health, MHH, inclusion and access are also evident on the blog. These include Hume’s musical narrative research into delirium, Kobus Moolman’s visceral poetry of the body and surgery, and an interview with Emmanuel Omobowale, the founder of the Institute of Bioethics and Medical Humanities at the University of Ibadan, Nigeria.

This special issue is interested in inclusion, access, and social justice across various dimensions; it acknowledges the edgelands that many involved in MHH occupy. It also recognises that rhizomic connections exist beyond geographic, disciplinary, and temporal boundaries and connect practitioners, creators, explorers and nurturers of MHH wherever they are based. Some of the contributions to this special issue explore the evolution of the field and discuss the development of MHH in South Africa, and elsewhere on the continent. These accounts include experiences of the field in spaces where it is established and spaces where it is not, thoughts and critical reflections on what has been achieved, and commentaries on what still needs to be done. Other pieces consider praxis and performance in various fora—from lecture theatres, to research spaces, to public health interventions and public engagement activities. They provide examples and accounts of researchers challenging or troubling disciplinary boundaries. Some of the discussions relate to methodological, philosophical or intellectual questions concerning MHH, while others are more firmly rooted in research practice, examples of educational pedagogy, and the challenges and strengths of undertaking work that troubles existing disciplinary boundaries and is not wedded to one definition of MHH.

This special issue is a contribution to the journal’s interest in publishing articles addressing innovations and developments in the field of MHH (such as vol. 41, June 2015), by showcasing reflections on, and developments in, the field by people based in South, Southern and other parts of Africa. It contributes to the new and exciting direction that the journal is pursuing by ‘offer[ing] points of connection between and among scholars, and … facilitat[ing] … dialogue’6. The special issue and its accompanying blogs and podcasts have branched from existing rhizomes in the field, and act as dimensions or middles overspilling from parts of Africa, connecting multiplicities, and linking edgelands to nurture growths in new directions.

References

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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