In Reply to Ventres

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Dr. Ventres’s proposed concepts provide a helpful framework for health and humanitarian workers from high-income countries (HICs) like the United States working in the low-resources settings (LRSs) of Sub-Saharan Africa. His concepts align with his previously published REVOLUTIONS social accountability framework,1 which proposes a shift in medical education curricula from such orientations as individualistic, prescriptive, technical, and patient-centered towards participatory, global, social, and community-centered orientations.
The concept of engaged presence is valuable insofar as it goes beyond the “transactional” engagements that often characterize global health interactions and includes the contemplative quality of “presence.” Visiting humanitarians and health professionals working in LRSs may need to more mindfully ponder questions such as, Who are we engaging with; why and for what purpose; and with what expected outcomes and consequences? Such engagement demands “presence.” Global health as a discipline is still tinged with philanthropic attitudes rooted in “us-versus-them” altruism and “othering.”2 Too often, global health involvements entail sporadic and unsustained interactions instead of a more desirable sustained and engaged presence.
Reciprocal development is a concept helpful for reorienting engagements in global health from top-down, philanthropic interactions towards horizontal, reciprocal engagements. Reciprocal engagement may include self-interests3 but also entails a bidirectional reaching out and involvement between partners for mutual benefit. Crisp4 talks about “Turning the World Upside Down” as a metaphor for learning bidirectionally from other societies and cultures in developing countries. Individualist societies like the United States have much to learn from collectivist approaches to learning in Africa. In particular, we need to guard against the temptation to franchise and export our “superior” Western medical education and accreditation systems to developing countries—a tendency that haughtily ignores local cultural and epidemiologic contexts, and that Bleakley et al5 have pithily termed the “McDonaldisation” of Western medical education.
Finally, the concept of “decolonization” draws attention to the historical contexts of Africa that have profoundly shaped its identity, and continue to exert their effects through power hierarchies, domination, and elitism. Health and humanitarian workers from the United States and other HICs may have scant grasp of the depth of colonialist wounds on African identity. But such an understanding is essential for apprehending the prior concepts of engaged presence and reciprocal development. Dr. Ventres rightly suggests decolonization as a strategic paradigm for curriculum development in Africa.
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