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What are the things in your world and the way you experience it that you don’t see, to which you are somewhat blind, because you are so deeply imbedded in your cultural conditioning?
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The Emergence of Global Medicine
Ed. note: In the following dialogue, excerpted and edited from IONS’ Essential of Noetic Science teleseminar series, doctor-educator Sylver Quevedo talks with IONS Media Director Angela Murphy about his work in Africa and his efforts and those of his colleagues to bring a multicultural perspective to the practice of medicine.
Angela Murphy: Dr. Quevedo, you are a Western-trained physician with a Latino and Native American heritage. Would you tell us how you integrate multicultural practices into your medical practice?
Sylver Quevedo: When I was growing up, I heard lots of stories in my family about traditional methods of healing and the mythology that goes along with that. In medical school, I was still interested in traditional healing, although at that time, we didn’t use the term “integrative medicine.” Then it was more a matter of different ways of knowing and of experiencing the world. In fact, even early on, some of us thought that there ought to be a topic that we would have called comparative epistemology, because it appeared that the world wasn’t the same everywhere. When I traveled, I often found myself sort of between worlds and not sitting in any one particularly well. So, with that as backdrop, I’ll say that I’ve always had an interest in the cross-cultural aspects of medicine. Almost as a necessity, I found it important to try to understand medicine and healing from different vantage points.
In years back, this was the subject area of medical anthropology. But anthropologists were always a little bit suspect by indigenous peoples—certainly in the United Sates and probably in a lot of places around the world—because anthropologists tended to objectify another person’s reality in a way that was somewhat artificial. I think it stemmed from an attempt in the social sciences to try to mimic the hard physical sciences by dividing the world into the “objective world,” which was considered valid, and everything else, which was less valid. You know, among the indigenous in this country, they say that some places in the world have earthquakes, others have floods, but for the tribal natives in the United States, there are anthropologists. So, there has been this view of anthropology as a discipline that tends to dehumanize the subjects of its study. Some of my friends moved away from anthropology early on and went into comparative religion instead, arguably because they found that field a lot more conducive to their way of seeing the world. Since the mid-1960s, however, anthropology has changed quite dramatically. I think it’s a very interesting discipline now where the discourse on comparative epistemologies is central. Today, I find anthropology to be an exciting way of looking at not only other cultures but also our own culture and the fundamental human experience.
Among Native Americans in the United States, there is a sort of aphorism that anthropology starts at home, and it is interesting as a point of departure to ask the cross-cultural questions about yourself. What are your implicit assumptions? What are the things in your world and the way you experience it that you don’t see, to which you are somewhat blind, because you are so deeply imbedded in your cultural conditioning? If we take the perspective of Clifford Geertz, one of the major figures in contemporary anthropology, one way of thinking about culture is that it’s a context, a set of interconnecting beliefs that give meaning to experience that is shared with other people. This is something that starts the moment you’re born—and possibly before that—inculcated into the way that you see the world.
If we use Geertz’s perspective as our point of departure in medicine and healing, then cross-cultural medicine is something that happens pretty much every day in every medical setting. With the increasing pluralism we find everywhere in the world, it’s quite difficult for a healing practitioner to try to understand how people with different languages and from different cultures are experiencing a problem and then to translate that to some degree into how you see it and arrive at a mutual understanding for a course of action or therapy. Actually, this is an approach that was advanced by Arthur Kleinman, a physician and anthropologist from Harvard, in an important medical article he wrote in 1977. [see “Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research” by A. Kleinman, L. Eisenberg, and B. Good]. That article made the argument for an explanatory model with elements of commonality that you could sort of carry around for any consultation. It has a great deal to do with how patients not only experience their particular illness but also how likely they are to follow instructions for dealing with it, and beyond that, it also has something to say about your own understanding of illness.
I think cross-cultural medicine is very much the norm. People outside the United States don’t use the term “integrative medicine”; it’s “global medicine,” because medical traditions from different cultures are encountering one another with increasing frequency literally everywhere in the world.
Murphy: Your description of our cultural perspectives and how we come into healing from our own upbringing and perspective is what we’re working with in the Institute’s Worldview Literacy Project—how we know what we know and how we each have different perspectives.
Tell us a bit about your experiences with ceremonial medicine and bringing different indigenous practices into your medical practice.
Quevedo: First, I want to comment on IONS’ Worldview Literacy Program. I think it’s very much in concert with what I’ve been talking about, and I think it’s going to become a requirement during this period of globalization we find ourselves in. It’s more and more a necessity to be able to negotiate and to be comfortable with the terrain of different perspectives and the worldviews of other people. It’s also part of the foundation of building peace in the world. I think this is important work.
One of the things that comes up along this line of work is what we’re doing in Africa with the notion of singular identities—that is, the idea that people have a singular identity such as American, British, Kenyan, Makoda, Tocano, or Masai. This idea of a singular identity is really a fiction. People have multiple identities. For example, they’re Muslim or Christian and American and male and a son or a daughter. We have several identities, and this notion of multiple identities present in every person gets to the heart of multiculturalism. It’s truer to fact that people have multiple identities. In fact, there is a view that singular identities are largely political constructions, a view for hegemonies or power structures or power dynamics. In Africa, this is a huge discussion. Amartya Sen, an economist who won a Nobel Prize and who is now at Harvard, wrote a book a couple of years back titled Media and Violence: The Illusion of Destiny, in which he basically makes the argument that people have multiple identities and that it’s important to understand this. In Africa, there’s an aphorism going around about the economy of adversity, which is that “hybridity is the norm”—in other words, people are mixed in many ways.
In Kenya, that country’s transition from tribalism to a kind of national identity has led to lots of discussion about what it means to be a member of a tribe, both the positive and negative aspects, and what defines identity. There’s a booming economic development occurring in East Africa right now, and a lot of people there are still very close to traditional life and live in tribal societies.
Murphy: Since you’re talking about Africa, tell us what you’re doing in Kenya right now.
Quevedo: I’ve been going to Kenya for more than four years now as chair of the board of an American nonprofit that is a sister to the Nairobi-based Trust for Indigenous Culture and Health, or TICAH. TICAH was founded by Mary Ann Burris to focus on the positive aspects of health and healing from traditional cultures. In some parts of Africa, particularly in Kenya, traditional healers are viewed pretty much as witch doctors (a legacy of the missionaries). Mary Ann and I have been working together with women and children in very poor areas of Nairobi and Kenya using traditional healing approaches (botanicals, herbals, etc.) and contemporary healing methods as well. We’re doing lots of projects there, including HIV education, sex education, as well as kitchen gardens that allow people to grow their own herbs and such.
Through that work, I got to know some of the people at The Aga Khan University. After I gave a series of talks there on medicine and science for the twenty-first century, I was asked to join the faculty as a visiting professor and to participate in two projects. One of these is the development of a new medicine school with a global medicine curriculum. The Aga Khan University runs a post graduate medical school and a hospital in Nairobi—actually several hospitals and post graduate programs that are residencies in surgery, anesthesia medicine, pediatrics, obstetrics and gynecology, and so forth.
Murphy: Are you developing a curriculum of integrative medicine and traditional healing practices alongside allopathic medicine?
Quevedo: Yes, the idea is to develop a new medical curriculum with interdisciplinary aspects that are cross-cultural in many ways. It introduces the students to several different systems of healing, to traditional healers, and to many newer approaches that are being used around the world, such as more participatory approaches with patients as well as some of the cutting-edge developments in science and technology. For example, there’s a stem cell biology program in partnership with the University of California San Francisco, as well as a neuroscience partnering program. So, the curriculum doesn’t shortchange Western science or allopathic medicine at all but brings it into a more integrative approach with other systems of healing such as Traditional Chinese Medicine.
There are actually a lot of Chinese medicine practitioners in Nairobi and more and more Chinese in East Africa. There are also a lot of Indians in East Africa, which began during the colonial period when the British brought the Indians to Africa as indentured servants for the railroads. As a result, there is a lot of Ayurvedic medicine in Africa as well.
Anyway, the aim of our curriculum is to bring together the best of all the healing approaches, to learn from them, and where possible to develop some synergies. It is a global medicine curriculum. The interdisciplinary aspects are interesting as well, for the university also wants the humanities and the arts integrated into the teaching of medicine. They don’t want the medical school simply to be an applied sciences/engineering type of school. They want a much older model in which the arts and humanities are integral to the training of physicians.
Murphy: How do they do that?
Quevedo: That’s the subject of lots of discussion. Several things are being planned for this six-year post-secondary curriculum. After secondary school, students will enter the six-year training program, which will be comprised of two years of a core curriculum and four years of a professional curriculum. They will graduate with a master’s degree and a medical doctorate.
An interdisciplinary faculty will teach the first two years of the core curriculum, covering the social sciences, the humanities, and the arts. The last four years will involve a preclinical and a clinical phase—not that different from a Western medical school. However, four longitudinal strands will run through the entire six-year curriculum, with time dedicated to each one of them at each stage: these strands are Ethics and Global Citizenship, New Frontiers in Science and Knowledge, Population Perspectives on Health, and Medicine and Humanities. The principal responsibility of the core faculty will be to organize the interdisciplinary activity for each of the phases. Students will be team-taught—for example, they will study ethics with people from philosophy as well as from medicine. The idea is never to have the various disciplines entirely separated from interdisciplinary activities.
It’s a fascinating project with more than thirty people involved in the curriculum development group, which has been meeting for several years. The first classes are scheduled to start in 2015—that’s the plan, anyway.
Murphy: Tell us a bit about the collaborative process in all this.
Quevedo: Well, there are a whole lot of issues in giving form to and structuring this vision so that it’s manageable. The University of Alberta is partnering with Aga Khan University in this endeavor. The undergraduate campus is going to be in Arusha, Tanzania, which is right on the border of Tanzania and Kenya, and the medical campus will be in Nairobi—to begin with. The plan is for the nursing students and the medical students to be in the core curriculum together and to some degree to share classes throughout the entire program. But the first two years they will literally be in the core curriculum together. So, there’s a lot of discussion about how that’s going to work.
There is also a robust discussion about pedagogy and pedagogic models. We would really like the learning to be an active, creative process—and incidentally, it was prayer that inspired this view. We are factoring in the different learning styles and the sort of multiple intelligences that Howard Gardner describes. Some people are kinetic learners, others kinesthetic learners, some people are better at communications and relating, and others at mathematics and logic. All of these different aptitudes are important. Literature and storytelling are equally as important as mathematics and molecular biology. So, several different approaches will be involved. There will be a large lecture format as well as discovery learning, where small groups of students solve problems collaboratively. There will also be opportunities for self-directed learning, independent study, and research.
Debate continues about whether or not student-directed activities should be entirely extracurricular—here I mean student societies, student-led initiatives, and student-led courses in which students plan the educational activity. The arts will foster their own performance activities, making theater and poetry readings, for example, a part of the curriculum.
So, because we are factoring in different pedagogical approaches and educational strategies, this has been a complicated process of mapping out what a typical semester will look like. There have been lots of heated debates on what’s best. Suffice it to say that the faculty of arts and sciences and the faculty of health sciences from Aga Khan University, which are the two faculty groups leading the effort, have been quite courageous in saying that we are going to do this—we’re going to try this and learn from the students and from our mistakes, but we know we want to go this route. So the commitment has been quite strong. Dr. Rushi Kasachi, the faculty leader, is really committed and has been an inspiration to carry on with this endeavor.
Murphy: Will traditional healing practices be included in the curriculum?
Quevedo: The university creators are very aware of the surrounding community, so there has been lots of discussion about relationships with the community, sustainability, and what resilience models in ecology call “human ecology.” Traditional societies and traditional healers are very important, not only as a source of wisdom passed down through the culture and the ages but also as an immense resource of practical knowledge about plants, animals, and the environment. Tapping the knowledge that these stewards and wisdom keepers hold is central to the discussion.
How all this will fit into the medical practice is still an open question. Right now, there are actual laws in Kenya that oppose traditional practices, so-called witchcraft laws, although most people are going to traditional healers in one form or another nonetheless. We just did a survey with TICAH (through a Rockefeller grant) that looked at the prevalent use of traditional healing, and traditional revenue, such as from botanicals, is quite high—as it is pretty much anywhere you look in the world. But Western allopathic doctors are really not part of that dialogue, and I think that’s a major failing in Western medicine.
Murphy: Well, it wasn’t that long ago that acupuncture was illegal in the United States.
Quevedo: To me, that is mind-boggling. But I guess anything’s possible when it comes to politics.
Murphy: That is changing rapidly all over the world, though; we’re going back to traditional medicine in some cases, which is exciting.
Would you talk about what’s coming up? What is the cutting edge?
Quevedo: There is another project I’m involved with in Kenya. Interestingly enough, as I was becoming involved with Aga Khan University, the University of California San Francisco was also in discussion with Aga Khan University to form a partnership. They’ve done that now under the leadership of Haile Debas, who used to be the Dean of UCSF Medical School, as well as the Chancellor at one point. Haile is the founder of the Global Health Sciences program at UCSF. He is an amazing person and a real leader not only in academic medicine in the United States but also throughout the world. He was instrumental in forming a partnership with Aga Khan University to develop a model health system in Kola, which is a stretch of land in Kenya from the Nairobi area to the Mombassa Coast, with a population of about 300,000. So, UCSF has partnered with Aga Khan University not only to develop a model health system but also to share faculty and students through exchange programs, with the explicit goal of developing local capacity and learning about and supporting the people of East Africa—Kenya in particular.
In UCSF’s partnership with the Aga Khan University, we’re looking at issues that pertain not only to health but also to a sort of person-powered development in these communities. Aga Khan is an amazing institution because it runs hospitals, which are not governmental but private institutions, and also works with people who have no resources through something called the Aga Khan Development Network. This is a whole subsystem in the Aga Khan institution that does philanthropic work—but with a very different model than we’re used to in the United States—using schemes such as microfinance and microinsurance. The idea of the Aga Khan Development Network is not to give people fish but to teach them how to fish, that kind of thing. They want to create self-sustainability and self-determination by partnering with people. They use a model called Multi-Input Area Development, which addresses health services, water, food, sanitation, transportation infrastructure, income generation capacity, and microfinance. It’s a much more holistic approach to development. It’s remarkable to be involved in those discussions, and it’s complex to say the least.