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Towards a transformative health humanities approach in teaching the Sustainable Development Goals (SDGs)
  1. Eivind Engebretsen
  1. Sustainable Health Unit (SUSTAINIT), Faculty of Medicine, University of Oslo, Oslo, Norway
  1. Correspondence to Professor Eivind Engebretsen, Sustainable Health Unit (SUSTAINIT), Faculty of Medicine, University of Oslo, Oslo, Norway; eivind.engebretsen{at}medisin.uio.no

Abstract

The adoption of the United Nations' Sustainable Development Goals (SDGs) marks a significant shift in global political agendas, emphasising sustainability in various fields, including health. To engage meaningfully with sustainability, a transformative educational approach is essential. Lange’s concept of transformative learning encompasses three levels: personal and cognitive change (micro level), changes in our interactions with others and the environment (meso level) and societal changes (macro level). This paper posits that applying health humanities approaches, particularly narrative medicine, can enhance transformative education at these three levels, leading to a powerful, transformative health humanities framework for teaching sustainability and the SDGs. This interdisciplinary method, which includes reflective self-assessment, exploration of different relational perspectives and social reality comprehension, facilitates transformative learning. However, implementing this transformative strategy requires a critical reassessment of some core principles and methods within the existing health humanities paradigm.

  • health care education
  • narrative medicine
  • Medical humanities
  • medical education
  • physician narratives

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Sustainability represents a paramount challenge of our time, encompassing various aspects of society, including healthcare. The integration of the United Nations' Sustainable Development Goals (SDGs) into political agendas globally highlights a growing focus on achieving sustainability across various sectors. Within the context of this transformation, health humanities emerge as an interface of disciplines that can further challenge, inform, and refine our understanding of sustainability and the SDGs.

The SDGs have been criticised for being underpinned by Global North and neoliberal interests (Arora-Jonsson 2023) and for being limited to talk while action at the deeper regulatory and institutional levels has been limited (Biermann et al 2022). Scholars have even claimed that the SDGs are inherently ‘unimplementable’ because they are framed as indisputable ‘interventions’ to be ‘rolled out’ in different settings with progress monitored using standardised metrics (Engebretsen and Greenhalgh 2024). The increasing focus on sustainability, coupled with criticism of the official framing of the SDGs, underscores the urgent need for a radical approach to ecoliteracy, especially in the field of medical education. As highlighted by Kahn (2010), there is a pressing need to address the crisis of environmental education being used as a mere ‘greenwash’—a superficial commitment to ecological causes that acts as a smokescreen, obstructing rather than fostering meaningful engagement with the inherent complexities of sustainability. Through health humanities, we have an opportunity to debunk misconceptions, diminish academic isolation and inspire the collective critical reflection required for a genuine commitment to sustainability (Engebretsen et al 2023).

But the intellectual voyage required to engage with the concept of sustainability meaningfully must be transformative. According to Lange (2019), transformative learning may be broken down into three levels. The process begins on a micro level when people start to develop a more nuanced understanding of sustainability. This is a stage of self-reflection and cognitive transformation that prompts individuals to reassess their own personal choices and actions. The journey then transcends to the meso level, which promotes a deeper understanding of the wider impacts of human actions on society and the ecosystem. This stage encourages a sense of shared responsibility for the sustainability of our planet and represents a change in how people interact with others and the wider environment. Finally, the journey culminates at the macro level, where system-wide reforms in the political, economic, technological and ideological domains are recognised as necessary to attain sustainability. The final level proposes a transformative education with the goal of changing society, pushing us to reconsider and rework our social structures in order to make them more resilient.

The three stages of transformative education focus on different aspects of change: (1) Personal change and cognitive transformation (micro level), (2) Changes in our relationships with others and the environment (meso level), and (3) Societal changes (macro level). This transformative process of learning remains underanalysed and underincorporated in sustainability studies, contributing to failure to achieve substantial change. Despite setting out to effect transformation, current sustainability initiatives often fail to trigger profound changes, particularly in confronting deeply rooted colonial assumptions within the SDG discourse itself (Engebretsen et al 2023).

In this paper, I argue that the integration of methods from the health humanities, especially narrative medicine, can deepen and enrich these three levels of transformative education, thus instigating a robust, transformative health humanities approach to teaching sustainability and the SDGs. Through this interdisciplinary approach, embodying reflective self-assessment, exploration of relational perspectives and understanding of social realities, transformative learning can be facilitated. However, adopting such a transformative approach necessitates re-examining certain foundational principles and methodologies within the current health humanities paradigm.

Drawing on Lange’s model, I will outline the three dimensions of transformative learning and demonstrate how these dimensions can be broadened, enriched and translated into the field of medicine, by incorporating approaches from the realm of health humanities, particularly narrative medicine. Moreover, I will argue that such integration necessitates a re-evaluation of some of the methodologies and analytical concepts within health humanities, thereby introducing a novel, transformative approach within the discipline.

The concept of ‘transformative’

Agenda 2030 has often been characterised as ‘transformative’, as evident in the title ‘Transforming Our World’ (Islam and Iversen 2018). The term has three separate meanings in the Agenda. First, it signifies a complex transformation that can lead to economic, social and environmental change. Second, the Agenda supports a transformation that is universal and encompasses all countries. Unlike the preceding Millennium Development Goals, which primarily focused on so-called ‘developing’ countries, the SDGs offer a global vision, targeting both poor and wealthy countries. Lastly, and significantly, transformative change represents enduring development. This perspective is embedded in the definition of sustainable development, originally introduced by the Brundtland Commission: development that fulfils ‘the needs of the present without compromising the ability of future generations to meet their own needs’ (Brundtland 1987).

On a deeper level, the concept of sustainable development embodies a twofold pledge: first, to foster scientific and technological advancement for optimising global resource utilisation; second, to continually scrutinise these same advancements to prevent excessive consumption of natural and human resources (Engebretsen, Wahlberg, and Ottersen 2021). The concept thus signifies a global promise for continued growth, encouraging hope and proactive engagement to fulfil this promise. At the same time, it depicts sustainability as a threshold, suggesting a potential crisis if this threshold is surpassed through excessive growth and calling for continued critical inquiry.

The impetus for promoting transformative learning in the context of the SDGs stems from what Kristeva (2010) has identified as two distinct interpretations of modernity and their corresponding modes of conceptualising the future: The first interpretation perceives the future as a promise, a purpose, or a target to be actively pursued. The progression towards this goal can be planned and measured. The related concept of knowledge or approach to this future vision is hence calculation. Kant identifies reason as the ability to adjust to a cause, whether divine or moral. With the advent of industrialization, this cause has increasingly become economic and technological. Kantian reason is this capacity to conform to “the logic of cause and effect, Hannah Arendt would say ‘the calculus of consequences’, ie, the logic of production, of science and of the economy” (Kristeva 2010, 15).

The second interpretation of modernity sees the future as an expansive horizon and a potential risk. From this perspective, crisis and critique become the norms for modern consciousness, with critical questioning being the primary mode of knowledge (Koselleck and Richter 2006). The idea that everything could be different and is fundamentally debatable emerges from this heightened awareness of potential future crises. As such, the future is fundamentally incalculable (Kristeva, 2010) and has to be continually reassessed and reconfigured.

The transformative approach to health humanities I seek to promote underscores the second of these two interpretations of modernity: it prioritises the possibility of profound change, of the future as a terrain that is amenable to being critiqued and rethought beyond the logic of production, science and the economy. Accordingly, the educational approach I propose is informed by the following key principles (Engebretsen et al 2023):

  1. Inspiring students to question the very systems that have engendered both the crises associated with sustainability and the dominant discourses about resolving them, in line with Audre Lorde’s enduring wisdom, ‘The Master’s Tools Will Never Dismantle the Master’s House’. We must motivate students to envision beyond the confines of existing structures and discourses, especially those already implicated in creating the current crises.

  2. Equipping students with the intellectual tools that can allow them to critically dissect the assumptions, foundations and biases underpinning the prevailing narrative of sustainability. This requires a shift from a didactic position (these are the facts) to a transformative stance: here are the divergent perspectives—how can you critically evaluate them?

  3. Emphasising the importance for students to realise that an uncritical green transition can result in 'green colonialism'. It is imperative to honour local systems of knowledge, indigenous practices and native wisdom in our thinking about sustainability.

These principles reflect and aim for transformation at the three levels delineated by Lange (2019) and further developed here—micro, meso and macro.

Micro-level change

The concept of transformative learning was first presented by Jack Mezirow (1985), pioneering the domain of adult education. For Mezirow, transformation involves drawing on one’s experience and developing the ability to critically assess one’s belief systems or cognitive frameworks, as well as becoming aware of others’ tacit assumptions and expectations. This transformation is precipitated through reflective dialogues, providing adults with a platform to interrogate the paradigms that shape their worldviews and emotional responses. Transformative learning, then, is ‘the process of becoming critically aware of how and why the structure of our psychocultural assumptions has come to constrain the way in which we perceive our world, of reconstituting that structure in a way that allows us to be more inclusive and discriminating in our integrating of experience and to act on these new understandings’ (Mezirow 1985, 22). In my proposed model, as I argue later in this section, the concept of narrative is central to such a transformative process.

In the field of medicine, Brody (2011) notes that one of the key elements of the medical humanities consists of an agenda of critical reflection aimed towards questioning assumptions that guide medical professionalism. Similarly, Charon (2001) posits self-reflection as an extraordinarily effective therapeutic tool at the disposal of physicians and proposes story-telling as its primary instrument. For Charon and other scholars in the field of medical humanities, stories function as devices for thought and reflection, as opposed to their use in the social sciences as qualitative data to be explored rather than as intrinsically valuable knowledge. Instead of viewing stories as sources for extracting themes and patterns to support broader sociological or psychological theories, they are regarded as inherently significant for shedding light on the intricate interplay of emotional, ethical and personal aspects in medical encounters. Charon (2001) highlights literature as the entry point into the art of story-telling:

Literature seminars and reading groups have become commonplace in medical schools and hospitals, both for physicians to read well-written stories about illness and to deepen their skills as readers, interpreters, and conjurers of the worlds of others. Having learned that acts of reflective narrating illuminate aspects of the patient’s story—and of their own—that are unavailable without the telling, physicians are writing about their patients in special columns in professional journals and in books and essays published in the lay press. Increasingly, physicians allow patients to read what they have written about them, adding a therapeutic dimension to a practice born of the need for reflection. Through the narrative processes of reflection and self-examination, both physicians and patients can achieve more accurate understandings of all the sequelae of illness, equipping them to better weather its tides.

From Charon’s point of view, engaging with literature can encourage a broader involvement with narratives, thereby integrating a therapeutic dimension into medical practice. This instrumental engagement with narratives recalls Mezirow’s emphasis on the need for learners to take charge of their critical reflection and learn from it. Like critical reflection, engagement with narratives serves to illuminate previously concealed aspects of both the physician’s and the patient’s experiences. Consequently, Charon identifies the humanities as foundational to the practice of what she calls ‘reflective narrating’, which holds the potential to instigate transformative change in diverse aspects of medical practice.

While this conception of narrative in narrative medicine holds promise for our proposed educational model, it is accompanied by several limitations. To begin with, the reflective capacity of stories is predominantly circumscribed to the patient-doctor relationship. Narrative medicine grew out of clinical practice: it was designed to teach healthcare providers to genuinely listen to their patients’ experiences (Slovic, Rangarajan, and Sarveswaran 2022). Due to its inherent clinical focus, narrative medicine has understandably zeroed in on the role of the individual patient. Despite emerging discussions that link narrative medicine with social justice (Slovic, Rangarajan, and Sarveswaran 2022), the clinical lens constrains the broader applicability of narratives in medical practice, restricting the capacity of narrative to provoke profound learning in other aspects of healthcare, such as policy discourses. It also obscures the role of stories in instigating transformative change beyond the individual story-teller. Restricting narrative to the doctor-patient dyad may thus hinder the realisation of its full potential in transformative medical education.

Second, the potential power of stories is further restricted by a relatively narrow conception of the core concept of narrative in narrative medicine. Narrative is understood as a distinct mode of discourse associated predominantly with literature and other overtly narrative genres, often excluding argumentative and expository modes of discourse. This perspective potentially obscures the richness and diversity of narratives that underpin other forms of discourse such as scientific articles, case reports or patient charts, where narrativity is evident not in the overt telling of a series of events but as a rationality that is embedded within the discourse—a set of assumptions about a taken for granted ‘reality’ that often escape scrutiny precisely because they are not overtly presented as an account of events. This restrictive interpretation potentially limits the scope and utility of narrative medicine by restricting its applicability to a specific set of discursive genres and contexts.

Third, as a mode of discourse narrative is often perceived as a privileged genre—hence the emphasis on literature. This may inadvertently elevate its status above other forms of communication, despite the valuable insights and perspectives that could be derived from them. The fundamental aim of Charon’s narrative theory is to ‘recognise, interpret, and be moved to action’ through stories. This romanticised understanding of narratives seems to persist within the medical humanities, even in cases where the application of narrative medicine extends beyond the confines of the doctor-patient relationship. This is evident, for instance, in recent attempts to use narrative theory in the interdisciplinary field of medical and environmental humanities in order to inspire ‘greater care for matter and life beyond the human’ (Slovic, Rangarajan, and Sarveswaran 2022).

For reflective narrating to truly align with the principles of transformative learning and transcend the limited scope of clinical self-reflection or rumination about interactions with individual patients, we must acknowledge that narratives are not inherently emancipatory, but are rather culturally embedded logics or rationalities that guide our thinking and demand our continuous scrutiny and assessment. Instead of simply focusing on discourses that are presumed to be more narrative and thus more emancipatory than other forms of discourse, self-reflection should mandate a critical examination of narrative elements within all discourses.

Embracing a broader understanding of narrative, I posit that it is not just a genre or mode of communication particularly relevant to the expression of personal experience, but rather a metacode functioning across all discourses and throughout all strata of social life. This means that even ‘scientific explanations apparently based on natural laws are actually a function of narrative procedures’ (Landau 1984, 267). From this perspective, narratives are not inherently positive or negative. Instead, they are intricate, evolving constructs that significantly influence patient experiences, healthcare practices and the creation of medical knowledge. This outlook highlights the need for transformative learning to involve identifying and critically assessing how various narratives intersect and shape one another within healthcare contexts.

Using Walter Fisher’s narrative paradigm as a foundation, I have previously proposed a theoretical model that offers an explanation of how stories are evaluated by their readers and listeners across different discourses (Engebretsen and Baker 2022). For the micro-level change pursued in transformative learning, Fisher’s narrative paradigm equips us with a framework for comprehending and reflecting on the process of assessing the numerous, often competing narratives to which we are constantly exposed. The model suggests that whereas traditional rationality leads us to believe that we evaluate competing narratives merely on the basis of whether they adhere to rules of logical inference, as human beings we all have a natural capacity for narrative rationality, which leads us to assess the stories we encounter on the basis of their resonance with our existing values and sense of identity. Fisher uses the terms ‘probability’ (assessing whether the story is coherent and consistent) and ‘fidelity’ (determining whether the story is credible, considering its context and the lived experiences of its receivers) to distinguish between these two principles. The model is descriptive rather than prescriptive; it aims to critically analyse the intersection of narratives where individuals, in this context students, find themselves, rather than to prescribe specific ways of assessing narratives. Additionally, it allows us to elucidate why some of these stories may resonate with some students while others may not.

In sustainability education, cultivating a learning environment that encourages students to reflect on the process by which they assess the probability and fidelity of prevailing recommendations, along with their affiliated controversies, is crucial. An example of a topic that can be debated in the classroom from this perspective is breast cancer screening, which raises sustainability conundrums in healthcare across economic, social and environmental dimensions. Manufacturers of mammography machines like Hologic and GE Healthcare, supported by several research groups, advocate for regular screenings, emphasising their instrumental role in early detection and improved survival rates. They assert that these early interventions diminish the burden of advanced disease treatment, thereby promoting better health outcomes, as well as economic sustainability through potential long-term healthcare cost savings. Adopting an opposing stance, another group of researchers has raised serious concerns relating to overscreening, overdiagnosis and overtreatment. They emphasise the excessive stress, potential physical harm, and economic hardship that regular screenings may inflict on women. This viewpoint indirectly underscores social sustainability, prioritising patient welfare and fairness in healthcare access. From an environmental sustainability perspective, the overuse of medical imaging contributes to healthcare’s environmental footprint, given the energy consumption of imaging machines and the waste generation from disposable associated products.

The evidence for and against mammography screening has been inconsistently interpreted and applied globally. This discrepancy has fostered a sense of ambiguity, disjointedness and scepticism towards both sets of recommendations and their scientific basis, further complicating the dialogue surrounding breast cancer screening practices. For example, in the UK, women aged 50–69 years are invited for mammography screening every 3 years by the National Health Service. In contrast, women aged 50–74 years in Australia are advised to undergo biennial screening while Uruguay mandates biennial mammograms for women aged 40–59 years. Even within the same country, the USA, conflicting mammography recommendations persist. The American Cancer Society (ACS) suggests annual screening from age 45 years and biennial screening from age 55 years, while the US Preventive Services Task Force (USPSTF) recommends biennial screening from age 50–74 years (Aschwanden 2015). These divergent guidelines leave physicians and women with the complex task of deciding which advice to follow. Ultimately, the question is whether it is justifiable to recommend a test that results in false positives for approximately half of the participants. Is it acceptable to risk potentially harming hundreds of women to potentially preventing a few breast cancer deaths? Policies adopted by both the ACS and USPSTF suggest that it is acceptable to harm a large number of women in order to prevent the deaths of an equally large number; this decision is based on a value judgement rather than simply scientific fact.

Writing for FiveThirtyEight, part of ABC news, Aschwanden (2015) demonstrates how different arguments appeal to different audiences:

After more than 15 years reporting on this issue, I’ve decided to skip mammograms altogether. My No. 1 priority is to remain a healthy person and avoid unnecessary treatments, and opting out of mammography reduces my risk of becoming a breast cancer patient by one-third. A smart friend of mine has examined the same evidence and come to the opposite conclusion, choosing to follow the ACS guidelines. She told me her priority is knowing that she’s done everything possible to avoid a breast cancer death, even if it means risking unneeded interventions and treatments.

Neither decision is devoid of reason. Various narratives resonate with individuals in different ways and appear credible based on alignment with their deeply held values and lived experience (Engebretsen and Baker 2022).

Situated at the intersection of such diverse narratives, micro-level transformative learning equips medical students with the capacity to reflect on and assess a variety of competing stories critically. It encourages them to consider the perspectives of all stakeholders involved, as well as their own, examining each narrative’s internal coherence (probability) and how it may or may not resonate with the experiences of the individuals who subscribe to them. It is through this capacity for narrative scrutiny and reflection that future healthcare professionals can navigate the intricate landscape of sustainability in healthcare, and contribute to reflective solutions that balance economic, social and environmental needs.

Meso-level change

The second version of transformative learning outlined in this paper draws on analytical depth psychology and organisational transformation theory, which offer a profound perspective on personality evolution. Here, transformation is understood to involve a radical alteration in personality, paving the way for the resolution of personal dilemmas and an expansion of consciousness, and ultimately leading to an enhanced personality integration (Boyd 1989; Lange 2019). This process encourages an in-depth exploration of our connection with fellow human beings and other species. Jungian theory, as advocated by Clark and Dirkx (2000), similarly unsettles the traditionally unified, autonomous and coherent perception of the modern self. It proposes the notion of self as being multiple, intrinsically conflicted and frequently driven by unconscious motivations. Transformative learning brings such internal conflicts to the surface, enabling a search for resolution and assisting in the integration of one’s multifaceted personality (Lange 2019).

As Lange (2019) argues, drawing on O’Sullivan and Berry’s (1999) transpersonal approach, this theoretical underpinning can be effectively applied to our understanding of sustainability issues. According to this viewpoint, our actions are not stimulated by rational concepts but by the dream structures rooted in our collective psyche, aligning with Jung’s suggestion that ‘the dream drives the action’. Symbols of the modern Western world act as incessant mantras, perpetuating a consumer-industrial consciousness that favours unchecked profit-making, views industrialisation as progress, and fuels the desire to consume. These mythical structures, embedded in our education and advertising systems, foster illusions of identity, belonging and meaning, while simultaneously promoting scientific and technological solutions to our societal issues. Only a significant shift in our cosmological narratives, introducing a different ethical perspective, can challenge this pervasive cultural programming (O’Sullivan and Berry 1999).

Medical humanities, since its inception, has anchored its approach in individual self-exploration (Evans and Greaves 1999). It traditionally viewed medicine as a unique form of human self-exploration, where our physical and experiential natures coalesce. The clinical encounter, thus, is not just an interaction between a physician and a patient, but an active forum for mutual transformation. The process of making oneself receptive to the experiences of others, and empathising with these experiences, is also highlighted as a key reason for urging medical students and professionals to engage with literature. As Charon puts it, ‘Very simply, one reason to encourage doctors and medical students to read is that, by reading, they are practicing acts of empathy and strengthening those forces of imagination, self-disregard, blessed curiosity about another, and transport into the world-view of another that are absolutely required of the effective doctor’ (Charon 2000). Nonetheless, this perspective of transformative self-exploration has several limitations in the context of transformative learning.

First, it adopts an anthropocentric view of self-exploration, primarily focusing on understanding another human being’s experiences. In doing so, the medical humanities perpetuate a reductionist divide between nature and culture. The field is often perceived as aligning with the art aspect of medicine, whereas evidence-based medicine is classified as science. This duality confines the medical humanities to the non-scientific aspect of medicine that does not directly engage with biological processes. It does not concern itself with nature, but only with the human side of medicine. As highlighted by Kristeva et al, the medical humanities tend to reduce the cultural dimensions of health to subjective facets of medical care, rather than addressing the 'hard' factors that underlie sickness and healing (Kristeva et al 2018).

Second, the materials frequently deployed in teaching and scholarly discourse in the medical humanities tend to promote an uncritical dependence on foundational concepts such as 'patient' and 'experience'. These concepts reflect Western perspectives on the self in relation to sickness and health. Moreover, medical humanities education aspires to decentre various 'objectifying' knowledges considered essential to Western medical practice, but the focus on teaching epistemology through Western cultural artefacts, ideas and ideals, including canonical texts, can unintentionally marginalise certain patients and healthcare workers (Hooker and Noonan 2011).

Kristeva et al have advocated the need for a translational approach to the medical humanities, acknowledging ‘the pathological and healing powers of culture’ and perceiving the human body as a ‘complex biocultural fact’ (Kristeva et al 2018). For the past decade, Julia Kristeva and Marie Rose Moro have collaborated with psychiatrists, social workers, health workers and philosophers to assist young individuals in navigating the challenges of cross-cultural dissatisfaction during their integration into new cultures. This project is deeply translational, fostering intersections across languages, cultures and systems of knowledge. It empowers young individuals to reinvest in and reinterpret their identities through a new linguistic framework, while also linking semiotic or prelinguistic modes of expression to the symbolic domain of established linguistic structures. A translational medical humanities framework can synergistically blend ‘notions and experiences of biological and socio-cultural contagion’, thereby transforming not only the academic realm of medical humanities but also the practical aspects of medical knowledge, practice and policy (Arnaldi, Engebretsen, and Forsdick 2022). The humanities have both creative and therapeutic potential; they serve not merely as instruments of care but also of healing. This view of the field necessitates a deep reassessment of the epistemological tools employed by modern Western medicine, advocating for an openness to differing approaches. Such openness does not equate to disregarding the paramount role of the biomedical model or succumbing to what Kristeva (2003) describes as inverse reductionism, which oversimplifies a biological condition by treating it as a mere social construct. Rather, it requires exploring possible entanglements between modern medicine and other knowledge systems that challenge and diverge from the dominant narrative.

On the Medical Society of Prince Edward Island (2023) website, the story of Dr Meghan Cameron highlights how embracing Indigenous knowledge can profoundly reshape a doctor’s identity and practice. Dr Cameron, who received her education at the Northern Ontario School of Medicine in Canada, which has a specific focus on providing healthcare to Indigenous people, was able to reconnect with her Mi'kmaw heritage. Within this educational setting, she was able to engage deeply with Indigenous healing practices, such as smudging and sweat lodges, and integrate these into her medical practice: ‘To be able to really help my patients, I need to have knowledge of these practices and what’s available to my patients so I can help them combine that with Western medicine. It also helps build trust’.

She acknowledges that providing healthcare in an Indigenous community is not devoid of difficulties: ‘It’s a lot to overcome to gain trust and it’s also difficult to help people navigate that trauma when I haven’t been through it firsthand. There’s been some progress towards reconciliation, but we have a long way to go’.

Cameron’s experience illustrates the significance of combining Indigenous and local knowledge with Western medicine to enhance patient treatment and establish trust within Indigenous communities. Furthermore, it emphasises the crucial importance of genuine engagement and deep reflection to ensure that this integration is meaningful and not merely superficial or an extension of a medical knowledge base mostly originating from the Global North.

By working with a case like this and sharing similar experiences, students can learn about their interconnectedness with others and cultivate a radical openness to different approaches.

Macro-level change

The third variant of the transformative learning model originates from the revolutionary theories of Brazilian educator Paulo Freire, whose work focused on the macro level of education, or rather, social change (Lange 2019). During the 1950s and 1960s, Freire started to develop a unique and liberating approach to literacy education, specifically aimed for peasants and the urban poor (Lange 2019).

Freire (2000) offered a critique of the conventional schooling system, which he referred to as ‘banking education’ to allude to the traditional role of teachers as banking clerks who saw their task as depositing knowledge in the minds of their students. In this model, teachers simply filled the minds of passive students with information they were expected to replicate in tangible products for evaluation. This approach to education, Freire argued, served to ensure the availability of obedient workers for an industrial, capitalist system, rather than fostering critical thinkers or change makers (Freire 2000; Lange 2019). In contrast, Freire advocated a dialogical approach in which learners are empowered to assume the role of active agents in guiding their own learning. As active agents, they did not collect isolated pieces of information but used the knowledge they acquired as a tool for examining the political and economic conditions that engendered their poverty. The process of learning was thus recast as a dialogue between teacher and learners, and among learners, about these conditions and possible ways of alleviating their hardships. Freire’s innovative approach underscored the transformative power of education, recasting it as a medium for social and economic critique, and ultimately, change. His focus on emancipatory education emphasised the collective empowerment of marginalised communities and provided them with the tools to understand and challenge the structures that perpetuate their poverty. This is the level at which the medical humanities could pitch their most important but also their less developed contribution.

The field of critical medical humanities has recently begun to address this gap within the broader context of the medical humanities. As an interdisciplinary domain, it strives to deepen our understanding of health and illness by shedding light on and critically analysing the power dynamics that shape these experiences. This progressive perspective goes beyond the traditional focus areas of ethics, education and experience, introducing a fourth dimension: entanglement. Entanglement in this context means recognising that the humanities is deeply and productively entangled with biomedical culture (Viney, Callard, and Woods 2015). And yet, there remains a notable limitation in both critical medical humanities and health humanities at large—their concept of health tends to be strikingly narrow. Critical exploration of the complex interdependence of biomedical, environmental, social and economic systems must exceed the bounds of the health system alone (Engebretsen et al 2023). Scholars and students in the health humanities need to address health not as an isolated concept, but as an integral component of a complex web of societal, environmental and economic factors.

Within the context of sustainability education, a critical medical humanities perspective promotes awareness of the challenges and trade-offs inherent in the pursuit of a just and sustainable future. It stresses that addressing the health implications of climate change requires more than reactive measures. It requires us to scrutinise the intricate interplay of social and environmental sustainability and to critically reassess the potential harms that may be inflicted by some aspects of the prevailing sustainability narrative. This further requires acknowledging and understanding, where necessary, the reasons for resistance to certain measures that may be taken in line with the SDGs. A prominent illustration of resistance to ecofriendly infrastructure initiatives can be seen in the case of the Sami minority in Northern Europe. This indigenous group, inhabiting territories spanning the Arctic polar circle, adamantly opposes large-scale wind farms and similar projects due to the potential harm to their livelihoods and the encroachment on their ancestral customs.

Norway’s commitment to transitioning to renewable energy led to the Ministry of Petroleum and Energy granting licenses in 2013, under the Energy Act, to build and operate numerous wind farms in the Fosen peninsula and Snillfjord area. However, a significant shift occurred in 2021 when the Norwegian Supreme Court deemed these licensing decisions unlawful, asserting that they infringed the rights of Sámi reindeer herders to maintain and honour their indigenous culture. The Supreme Court’s unanimous decision nullified the permits and expropriation authorisations for the construction of 151 wind turbines, yet it offered no guidance on the fate of these installations.

An interview with a Sami reindeer herder in France 24 underscores the inconsistency in the green policy that backed the wind farm’s development and its damaging effects on the environment. As the herder put it, ‘It’s impossible for the reindeer to come here now, with all the enormous disruptions caused by the turning and turning of the turbines, which scare them. And they make so much noise’ (France 24 2022). He also expressed grief over the introduction of car parks, roads and crossings, lamenting, ‘Nature has been completely destroyed here. There’s nothing left but rocks and pebbles’. Another herder acknowledged the need for a green transition but questioned its execution at the ‘cost of nature’.

The seemingly vacuous court decisions have eroded local trust in the judicial system. Sissel Stormo Holtan, a 40-year-old herder, explained: ‘Well, nothing has happened even though we won. It feels kind of weird, just starting a new fight all over again and it feels… unfair’ (France 24 2022). This sentiment reflects the prevailing disappointment among herders who had hoped for a decisive and consistent response from the legal system postvictory. Moreover, before the Supreme Court’s decision, a lower court had suggested financial compensation for the herders to mitigate the loss of their lands, allowing them to buy fodder for their livestock. The herders swiftly rejected this proposition, arguing that providing feed would compromise traditional herding. As Leif Arne Jama asserts, ‘The reindeer have to find their own food. If we give them feed, it’s not traditional herding anymore’ (France 24 2022). The court judgement thus displayed a lack of understanding of the environment in which the herders lived, failed to respect their unique herding practices, and was at odds with the local population’s experiences and traditions.

An approach rooted in reflection and empathy, cognizant of the narratives and lived experiences of the indigenous community, could have potentially circumvented the establishment of the wind farm in its current location, or at least, prompted a more informed discussion earlier. While not explicitly health-related, this case directly challenges deep-seated colonial frameworks within green policies, which carry health implications, especially in terms of understanding mental distress among indigenous populations. On a broader level, this example underscores the necessity for critical reflection on how narratives are assessed differently across diverse groups, highlighting their essential role in sustainable decision-making processes.

An emphasis on socially conscious education and research means that students are trained and encouraged to scrutinise the global aspirations that underlie the sustainable development model in global health. This can be accomplished by revisiting some foundational concepts that support the agenda, such as sustainability, well-being, equity, partnership and empowerment (Engebretsen et al 2023). Such essential global health principles have evolved to include diverse and occasionally contradictory ideological messages, encompassing both the call for worldwide unity and the demand for individual improvement and self-management (Engebretsen et al 2016). Inherent contradictions within these pivotal principles, as well as the instability of their meanings, open the door for manipulation. They can be co-opted to serve purposes that obscure certain vulnerabilities, deviating from the SDGs’ vision of inclusive progress. For example, medical technologies and treatments are often labelled as 'unsustainable' in communities where the need for such treatments is most critical (Farmer 2015).

A substantial obstacle to the effective incorporation of the sustainability agenda into a critical educational agenda is the widely held view that the core SDG principles are universally applicable. This perception can simplify the implementation process into a mere delivery pipeline, thereby inadvertently promoting a democratic deficit (Engebretsen and Heggen 2015) and lead to unimplementability (Engebretsen and Greenhalgh 2024). The transformative medical humanities model proposed here encourages students to understand these conceptual paradoxes and leverage these insights to question and re-evaluate the prevailing sustainability paradigm.

Towards a transformative health humanities approach in teaching the SDGs

This paper has outlined a transformative model of education and offered examples of how it might be applied in the fields of health humanities and sustainability studies, with an emphasis on three major principles and insights.

On a micro level, the proposed approach critically examines the reliability and veracity of existing SDG recommendations relevant to health, along with their associated controversies. It encourages students to interrogate the dilemmas inherent in these recommendations and to reflect on the complexities and nuances that underpin any proposed solutions, thus fostering the broader critical skill of analysing and questioning the prevailing narratives in any area of practice.

At the meso level, the approach cultivates deep empathy, encouraging an in-depth exploration of potential interactions between modern medicine and other systems of knowledge. This exploration may reveal contrasts and conflicts that challenge the dominant narrative. It thus provides students with a richer and more nuanced understanding of the multifaceted interactions between medicine and other knowledge systems, allowing them to develop a broader and more sensitive perspective on a variety of issues.

At the macro level, this transformative model underscores the need for critical analysis of the complex interplay between social and environmental sustainability at the societal level. Such an analysis requires students to develop a broader understanding of health that exceeds the traditional confines of the health sector. By considering health in its broader context, students can appreciate why health outcomes are not only the product of health-sector interventions, but are also influenced by a variety of social, economic and environmental factors.

The transformative model of health humanities education outlined above provides a layered and nuanced framework for understanding and teaching the SDGs, especially as they relate to health issues. Beyond imparting knowledge as such, this approach fosters the development of critical-thinking skills, encouraging students to challenge and reassess prevailing narratives and promoting a more holistic and integrated understanding of health and sustainability.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

Acknowledgments

The author thanks Prof Mona Baker for her meticulous review and insightful inputs to an earlier draft of this manuscript.

Bibliography

Footnotes

  • X @eivinden

  • Contributors EE is the sole author and guarantor of this manuscript. EE has used QullBot and ChatGPT exclusively for grammar checking and proofreading some sections of the manuscript.

  • Funding EE’s research is supported by the Centre for Sustainable Healthcare Education, a Centre for Excellence, funded by the Norwegian Directorate for Higher Education and Skills.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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