The violence of curriculum: Dismantling systemic racism, colonisation and indigenous erasure within medical education

Abstract

Background

Epistemic violence is enacted in medical curricula in mundane ways all the time, negatively impacting learners, teachers and patients. In this article, we address three forms of such violence: White supremacy, indigenous erasure and heteronormativity.

Methods

In this article, we examine the knowledge systems of medicine as a global phenomenon, impacted by Western and European ideologies of race and colonisation, both produced by them, helping to reproduce them through authoritative and hegemonic ideologies. We seek not only to problematise but also to propose alternative teaching approaches rooted in the Global South and in Indigenous ways of knowing. Taking inspiration from Paulo Freire, we advocate for the development of critical consciousness through the integration of critical pedagogies of love, emancipation and shared humanity. Drawing on Irihapeti Ramsden, we advocate for cultural safety, which emphasises power relations and historical trauma in the clinical encounter and calls for a rights‐based approach in medical education. Deliberately holding space for our own vulnerabilities and that of our students requires what Megan Boler calls a pedagogy of discomfort.

Conclusions and Significance

Our perspectives converge on the importance of critical consciousness development for culturally safe practice in medical education, acknowledging the need to emphasise a curriculum of shared humanity, introducing the concept of Ubuntu from Southern Africa. Ubuntu can be encapsulated in the phrase ‘I am because we are’, and it promotes a collective approach to medical education in which there is active solidarity between the profession and the diverse populations which it serves.

Short abstract

The authors confront the coloniality, systemic racism and Indigenous erasure inherent in medical curricula and propose a way forward through pedagogies of love and shared humanity.

1. INTRODUCTION: THE HARM INHERENT IN THE KNOWLEDGE SYSTEMS OF MEDICINE

As medical and health professions educators, we have had the privilege to witness students' flourishing through the application of knowledge gained in their nascent professional practice. Witnessing learners become physicians is perhaps the greatest reward for a teacher in medicine. There are also times in teaching and learning in which great distress and harm have been provoked within learners related to how specific subjects of study are being taught. Teachers can struggle to understand the processes that provoke learner distress, and it is often learners from structurally marginalised communities who experience the harms from what we teach and how we teach it.

There are three implicit agreements to which anyone joining the profession of medicine must agree, which link the knowledge gained to the social power of joining a community of professionals:

1. A willingness to think a certain way, which can be broadly characterised as ‘scientific’.

2. An openness to have one's thinking in and practice of the profession be reviewed by peers.

3. An acceptance that one will be socialised into a professional identity, which will allow for a stable and predictable professional ‘stance’, to be presented as a forward face of the profession as a collectivity enacted through individuals. ¹

In this article, we delve into how the curriculum of learning in medical education and the knowledge systems accessed to design it can be violent for learners, in particular learners from structurally marginalised groups. The process of harm in these situations is termed ‘epistemic violence’ (which we discuss and define below). To address epistemic violence requires that we as teachers develop the skills to critically examine the knowledge systems of medicine and their role in potentially reproducing injustices and inequities.

We address this article to any medical or health professions educator who has observed how learners may have been harmed through the curriculum of learning and who seeks to understand how teaching praxis might evolve to minimise harms and maximise learner flourishing. We will explore the theoretical grounding of concepts such as epistemic violence, racism in science and knowledge–power relationships in medical curricula. While the focus of this article is on learner harm, we draw links between what is learned and how it ultimately affects practice, including potential harms to patients.

To illustrate how harm might be incurred during the process of teaching, we invite the reader to consider the following scenario:

In first‐year medical school in Canada, a lecturer is conducting a session on type II diabetes. She is reviewing contributory genetic risk factors in Indigenous populations and highlights a study done in among the Anishinaabe people (an Indigenous nation in Northern Ontario and Western Manitoba) identifying a specific genetic allele, H320T, as an associated risk factor. During the lecture, she muses that this allele must have conferred survival advantage in this population from ‘back when they lived in teepees and hunted buffalo’. She points out that there is a complex interaction between ‘civilization and genetics’, which has produced the emergency that type II diabetes is today in ‘our’ Indigenous populations.

The Anishinaabe people have never lived in teepees and have never hunted buffalo.

An Anishinaabe student in the class, one of 3 from various Indigenous nations in a class of 150, looks up at her classmates, who are diligently taking notes on the lecture and thinks to herself, ‘Should I say something? About how an apple costs $4 and a Coke and a bag of potato chips cost $1.50 in my home community? About how much I am offended that she didn't even get my people's traditional livelihood right? About how the paper she is referring to did not even have any Indigenous co‐authors?’

‘Nah’, she says to herself, ‘It's just not worth it. Last time I did this, all they did was roll their eyes’.

When the Anishinaabe student looked up and saw her classmates diligently taking notes on the lecture, they were uncritically agreeing to understand ‘truth’ with respect to type II diabetes ‘scientifically’, through the lens and guidance of their ‘expert’ lecturer. The truth they learned in that moment was profoundly affected by hierarchies of power, ² which regulated what is knowable about type II diabetes in Indigenous populations and which creates blind spots to other ways of seeing and understanding healthcare. The lecturer's explanation was rooted in biologically deterministic notions of natural selection resulting from lifestyle ‘choices’ and failed to consider broader and more far reaching issues such as socio‐political and economic policies and social determinants of health. ³ The lecturer situated the cause of the health ‘deficiency’ within the person, rather than in that person's relationship to a highly unjust and discriminatory society, which is the actual influential social determinant in this case.

We can develop an understanding of how orthodoxy of thinking and standards of practice develop through learning and professional socialisation by examining the inherent knowledge–power relationships within the case. These knowledge–power hierarchies are imbued with the colonial relationships of ‘othering’ and dehumanisation from the settler society of Canada in which this scenario takes place. The knowledge systems that allow the ‘othering’ have arisen within histories of unjust and oppressive contacts between largely European nations and peoples of the rest of the world—what we term today as colonisation.

Early policies of ‘othering’, including the terra nullius doctrines of European settler societies ⁴ (‘the land was empty and therefore we settled it’) and the papal bull of 1493, which asserted the right of Spain and Portugal to convert, colonise and enslave the peoples of the world, ⁵ had direct effect on the lives and health of Indigenous peoples. If the land was empty, then what were the people living on it at the time of contact but part of the flora and fauna of the place? Both the terra nullius doctrine and the papal bull of 1493 erased the essential humanity of the Indigenous people that lived, and continue to live, in those lands. They set in motion an ideology of superiority permeating many forms of subsequent knowledge, including medical knowledge. In the scenario, the assessment of the value of the knowledge being presented ignored the social conditions under which that knowledge arose and how it contributed to creating and perpetuating health inequities, such as diabetes.

What should concern us with respect to the learning moment's contributions to the professional identity formation of the students in the class? The teacher's musings were received as ‘truths’, and we could justifiably be worried about the transmission of a toxic curriculum of othering of Indigenous people in this case. The Indigenous learner's professional identity formation would be much more complex. She would have had to negotiate belonging to a professional structure that has historically perpetuated colonial relationships while simultaneously producing and possessing useful and helpful knowledge for the care of patients.

In her seminal and famous postcolonial and feminist essay, “Can the Subaltern Speak?”, Gayatri Spivak coined the term ‘epistemic violence’. ⁶ She defined epistemic violence as forms of knowledge that actively construct marginalised persons as ‘Other’. The main actions through which epistemic violence operates are denial of experience and/or expertise, lack of reciprocation in dialogue and ‘pernicious’ ignorance. Examples of ‘pernicious’ ignorance include the privileging of certain ways of knowing, for example, Western biomedicine, over other ways of knowing, such as systems of Indigenous knowledge, with the effect of devalorising the unprivileged way of knowing to the point of invisibility. The ‘removal from view’ of Indigenous ways of knowing helps construct the creators of that knowledge as ‘Other’.

For the Anishinaabe student, the profoundly inaccurate and harmful musing on the part of the lecturer was a form of epistemic violence. Epistemic violence is enacted in medical curricula in mundane ways all the time. The lecturer's choice to engage in a biologically deterministic explanatory model, ignoring the richness of a multi‐pronged explanation incorporating social determination of health (and fitting with current scientific understandings, we may add) constituted a ‘pernicious’ ignorance.

In this article, we address the harm created by the knowledge systems of medicine to both learners and patients but also potentially to educators. We examine the knowledge systems of medicine as a global phenomenon, impacted by ideologies of race and colonisation, both produced by them, helping to reproduce them through authoritative and hegemonic practices rooted within paradigms of racism in science. ⁷ , ⁸ We seek not only to problematise but also to propose alternative teaching approaches rooted in the Global South and in Indigenous ways of knowing.

We have consciously sought to be diverse in our perspectives, moving beyond the original invitation of the submission, which asked broadly for there to be ‘Global North’ and ‘Global South’ voicing in any submission. One of us (SR) is a senior racialised medical educator in Canada, with a focus on issues of anti‐racism in health professions education, who continually negotiates the continuum between complicity and liberation as he participates in the enterprise of medical education in the ‘First World’ country he calls home, both as someone who has benefited from and been harmed by it. The second of us (LR) is an Indigenous Anishinaabe woman and internist practising in Toronto (Tkaronto), Canada, whose focus and expertise is in issues of equity. The third of us (SP) is a South African clinical psychologist, with Indian ancestry, who has experienced his country reckoning with its Apartheid past and the difficulties in undoing internalised forms of colonial thinking. Together, we hope to invite the reader on a journey, which lays bare the fallacy that the epistemological landscape is and has been a ‘terra nullius’ territory, to be populated and tamed with Western ways of knowing, but which rather contains within it a vast ecosystem and pluriverse of many useful forms of knowing, from diverse traditions.

This article builds on the body of writing in medical education that acknowledges how the ghosts of colonial thinking continue to haunt university classrooms, clinical ward rounds and patient consultations. We pay homage to the work of many writers who have long engaged with these issues. ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵

2. A PERSPECTIVE FROM A RACIALISED MEDICAL EDUCATOR IN THE GLOBAL NORTH: MEDICAL AND HEALTH PROFESSIONS EDUCATION IN SERVICE TO WHITE SUPREMACY IN MEDICINE

In a small group session on nephrology, renal transplantation guidelines are discussed, which use a formula to predict the level of renal function (e‐GFR), which contains within it a race correction factor for Black race (as defined in the United States). The formula is used to assess transplant eligibility.

The above brief scenario is an example of ‘race correction’ in medicine, which refers to the use of different algorithms of treatment for the same disease based upon race. ¹⁶ Race correction can also include different normal ranges used for laboratory tests. ¹⁷ It is a widespread practice in medicine, affecting areas of clinical practice as diverse as drug treatment recommendations, laboratory tests and electronic health record suggested treatment drop‐down menus. ¹⁸ , ¹⁹ As artificial intelligence (AI) has started to permeate medicine and medical education, there have also been examples from the various AI tools of discriminatory diagnostic and treatment suggestions based upon race or other forms of difference (such as gender), which are not scientifically supported in the medical literature. ²⁰ The use and teaching of race correction approaches in medicine has been widely criticised as a tool of increasing inequity. ¹⁷ In the example of renal transplantation given above, removal of race correction factors in the calculation of e‐GFR has been shown to increase eligibility of Black patients to the lifesaving therapy of renal transplantation. ²¹

At their basis, race correction strategies are rooted in ‘scientific racism’, defined as the pseudoscientific belief that the human species can be divided into biologically distinct taxa known as races and that empirical evidence exists to support the inherent inferiority or superiority of any particular race. ²² The genetics literature has long recognised that there is no genetic basis to race and that it is inherently a social construct. ²³ In the field of epidemiology, one of the recognised ways that racist approaches operate is in the demonstration of populational differences without the seeking or proposing of mechanisms for the observed differences, which at the very least consider the social construction of race—so‐called ‘black box’ epidemiology. ²⁴ From a historical perspective, the essentialisation of race as biological has deep roots in the eugenics movement, which provided the pseudoscientific ‘evidentiary’ basis for many medical horrors of the last century, including medicine in the Third Reich, the Tuskegee syphilis studies and eugenically derived sterilisation laws that affected Indigenous people disproportionately around the world. ²⁵ , ²⁶ , ²⁷ Eugenic thinking remains a central tension with much discussion in the field of genetics today.

Examples in medicine abound in which racial categorisation or other forms of difference are taught in ways that diminish the concerns of and portray as inferior persons of different racial groups or of other forms of difference. ²⁸ To give a gender‐based example, it is common to teach of the presenting symptoms of women with myocardial infarction as ‘atypical’ in comparison to men. ²⁹ A social choice has been made to teach one set of symptoms as ‘atypical’, that is, not in the ‘norm’. It is no wonder that there are well‐documented diagnosis, treatment and outcome differences between men and women presenting with myocardial infarction. Returning to the notion of White supremacy, racial treatment and outcome differences are ubiquitous in teaching and, at least in part, related to the racial hierarchisation that we see in terms of how disease prevalence and causality is taught with respect to racial groups.

Medical science has saved many lives. Medical science has also harmed many lives, and it has done so when there has been an uncritical examination of how its truths and findings have come about within social conditions in which great injustices based upon social difference persist. Science has not been apart from the injustices of society; it has been a part of them. ³⁰

In curricula, space must be provided to critique the scientific knowledge translation cycle—from test tube to bedside to patient context—for social and structural factors contributing to how disease and health are understood. In addition to critical appraisal, we must provide spaces for the teaching of critical theory and its relationship to medicine, such as critical race theory, feminist and critical disability studies, intersectionality and queer theories. One can imagine a few stand‐alone sessions, but very importantly, in appropriate content areas, the theory–praxis link will need to be drawn with embedded reflective teaching in order that learners can seamlessly see the relevance of such topics to outcomes with patients.

Traditional medical education is a pedagogy of standardisation. To meet the needs of structurally marginalised persons, it needs to develop an epistemological suppleness in learners such that, when appropriate, this standardising pedagogy can become a critical pedagogy. ³¹

We look to the works of Brazilian educator, Paulo Freire, for inspiration as to the skills or habits of mind that ought to be developed in learners for a pedagogy of greater equity. Freire distinguished two types of education—the traditional ‘banking model’ in which learners amass knowledge essentially to be agents in maintaining systems that frequently contain great injustices and education for emancipation, in which learners develop skills in reading the world for hidden injustices, and who then commit to act against these injustices. He termed this process ‘conscientisation’ with the end goal labelled as ‘critical consciousness’. ³²

Contained within the concept of conscientisation is the development of structural competence ³³ —the ability to see how social institutional practices (a mundane example might be how a patient gets a blood test in a hospital—are the pathways accessible wheelchair‐using persons? How does navigation work for a person who does not speak the language of the particular jurisdiction?) create structures that promote inequities between different groups. Such a skill requires critical reflection (‘What am I seeing and how?’) but also what we have termed as ‘refraction’ (‘What “glasses” am I seeing the phenomenon through?’ Epidemiology? Social sciences? Policy studies? Etc.).

In the nephrology scenario, there are opportunities to both reflect and refract. Reflection might include straightforward comparisons of access data by race in renal transplant populations. Refraction might make use of narrative methods, such as hearing patient stories about how their lives are impacted by such mundane unjust clinical decisions. It is not the scope of this article to exhaustively propose instructional methods. We point the reader to the works of Kumagai and Lypson as an excellent starting point. ³⁴

3. AN INDIGENOUS PERSON'S PERSPECTIVE: THEY HAVE NOT LEFT YET—RESPECTING THE SPECIFICITIES OF EPISTEMIC VIOLENCE AGAINST INDIGENOUS PEOPLES IN THE CONTEXT OF MEDICAL EDUCATION

A senior internal medicine resident assessed a patient with chest pain in the emergency room for admission to an inpatient medical unit. The patient was First Nations. The resident diagnosed the patient with a non‐ST elevation myocardial infarction. She reviewed the case with the attending physician and proposed to send the patient for cardiac catheterisation based on guidelines. After hearing about the case, the attending physician stated that it was not a good idea to perform angiography since the patient would not be compliant with anti‐platelet and other medications because as a First Nations person, he likely has ‘too many social issues’. The resident, who also identified as Indigenous, was shocked and upset by the response.

Medicine and medical education continue to cause harm to Indigenous patients, learners and communities. One of the ways in which healthcare institutions aim to mitigate harm is by building trust between Indigenous peoples and providers through the recruitment and training of Indigenous providers. During their training, Indigenous learners may observe racist attitudes and behaviours towards Indigenous patients and often experience interpersonal racism from colleagues and supervisors, compounding the mental, emotional and physical strain of medical school and residency. ³⁵ , ³⁶ Furthermore, as described in the preceding section, medicine and medical education perpetuate hierarchies of knowledge and expertise. Indigenous ways of knowing and being, including land and culture‐based understandings of health and well‐being grounded in hundreds of years of ancestral teachings, may be devalued, ignored or erased. ³⁷

The provision of high‐quality care to Indigenous peoples requires physicians to learn about anti‐Indigenous racism in the healthcare system. Dr Irihapeti Ramsden, a Maori nurse and scholar, developed the framework of cultural safety to emphasise the power relationships in interactions between health professionals and Indigenous peoples and how the ‘social, historical, political and economic diversity of a culture impacts on their contemporary health experience. Thus, structural influences, which have a significant impact on health status, cannot be ignored’. In describing the health inequities of Indigenous communities, curricula should explore how these gaps are linked to personal and intergenerational trauma caused by colonial government policies designed to assimilate or eradicate Indigenous peoples such as removal from traditional lands, attendance at residential or boarding schools, forced and coerced sterilisations and unethical experimentation and the disproportionate placement of children in the child welfare system.

The practice of cultural safety is a transformative one that requires providers to consider their situated identities and perspectives as bearers of culture and to confront the biases they carry. Formal Indigenous cultural safety training programmes designed for clinicians improves the quality of care they provide to Indigenous patients. But a focus on power relations, trust‐building and scrutinising one's own assumptions and worldview can strengthen how providers interact with patients and communities more broadly.

In Canada, the Truth and Reconciliation Commission's extensive archive of the stories of residential school survivors included specific Calls to Action related to health professional education such as the need for a mandatory course in Indigenous health that includes training in cultural safety, conflict resolution and anti‐racist practice. ³⁸ It calls upon leaders in health systems to value, recognise and provide access to traditional medicine and Indigenous healing practices and to uphold the international rights of Indigenous peoples. ³⁹

A rights‐based approach to medical education for Indigenous peoples and communities ensures that Indigenous learners, leaders, community members, educators, elders and practitioners inform all decisions related to Indigenous health curriculum and to the recruitment and retention of Indigenous learners. It reclaims the distinct role of Indigenous healing a pedagogical practices linked to local Indigenous communities, cultures and lands and, in so doing, highlights the strengths within Indigenous nations.

4. A QUEER GLOBAL SOUTH PERSPECTIVE: EMANCIPATION FROM COLONIALITY INVOLVES DISMANTLING HETERONORMATIVITY

During a psychiatric ward round, a masculine‐presenting transgender woman with schizophrenia is discussed among the multidisciplinary team. Despite the patient having a strong maternal and paternal history of psychosis, the psychiatrist, psychologist and nurse engage in a protracted discussion about the link between her sexuality and her schizophrenia, conflating her sexual orientation and her gender identity (she identifies as heterosexual, despite her medical record casually noting that the ‘patient is lesbian’). The patient's narrative that she is not lesbian is scoffed at. The patient is a recent refugee to North America from Uganda, where repressive anti‐gay/anti‐trans laws have been enacted. The treating team muses that at least her life is better in North America because no such laws exist. An international medical graduate from nearby Tanzania, who is undertaking advanced psychiatry training in the institution, reflects to herself that group seems to have no understanding of the impact of colonial era laws on the current structural discrimination experienced by gender and sexual minority people in the countries of East Africa and indeed in many other countries with histories of European colonialism.

This case provides an opportunity to develop learner and teacher conscientisation for a richer understanding of how colonial structures have impacted persons otherwise marginalised by sexuality or gender diversity. Through a comparison and contrasting of the origins and outcomes of gender‐ and sexuality‐based discrimination in, say, North America versus Uganda, there is an opportunity to examine paradox by consciously making the strange familiar and the familiar strange.

To make the familiar strange, we might begin by examining the rich homo‐ and transphobic history (and present) of both medical education and the care for persons from sexual and gender minorities. Despite attempts at improving medical education's ability to meet the needs of sexually and gender diverse patients in North America, ⁴⁰ , ⁴¹ , ⁴² evidence shows that LGBTQ+ health education remains inconsistent in medical schools in both the United States ⁴³ and Canada. ⁴⁴ In the South African context, Alexandra Müller ⁴⁵ found that the MBChB curriculum provided no opportunity for students to challenge their own attitudes towards LGBT+ patients and that even where LGBT+ content was taught, it was unsystematic and not incorporated into the overarching structure of the degree. Additionally, South African medical students had especially limited knowledge about transgender issues, ⁴⁶ echoing the substantial gaps in transgender medicine content among Canadian medical school curricula. ⁴⁷

The erasure leads to poor and inequitable health outcomes for LGBTQ+ people, which are well documented across the literature ⁴⁸ and perpetuate a vicious cycle of intersectional oppression for minority communities.

The exclusion of LGBTQ+ issues in the medical curricula is no accident—it is an outcome of enduring heteronormativity, underwritten by generations of colonial thinking around gender and sexuality—a thinking that frames gender and sexuality into rigid binaries of man/woman, male/female, masculine/feminine and heterosexual/deviant. Coloniality as a philosophical system needed to construct a world of simple binaries in order to cast the colonisers as benevolent and superior and the colonised as savage and inferior. According to Peruvian sociologist Aníbal Quijano, ⁴⁹ the control of gender and sexuality forms part of the ongoing ‘colonial matrix of power’—a violent, racist, capitalist and patriarchal superstructure of persistent global domination.

Queer erasure in medical curricula is an example of colonial violence. We can characterise such epistemic violence as ‘violence by exclusion’ (excluding LGBTQ‐affirmative knowledge in medical education) or ‘violence by inclusion’ (actively including pseudoscience that harms LGBTQ+ people). The former excludes relevant topics or evidence from the curricula, either deliberately or neglectfully. This creates a knowledge vacuum that deprives medical students of opportunities to learn about LGBT‐specific issues in healthcare, such as why children with gender dysphoria have a higher prevalence of suicidality than their cisgender peers. ⁵⁰ The latter, violence by inclusion, inserts problematic knowledge or topics into the curricula (e.g. legitimising sexual orientation change efforts or so‐called conversion therapies that are globally rejected as pseudoscience ⁵¹ ) and/or discusses LGBT+ issues in prejudicial or discriminatory ways.

These forms of violence stem from failures in medical educators to cultivate an affirmative, ethical and evidence‐based attitude towards patients who are sexually and/or gender diverse. However, medical education is shaped by the larger socio‐political systems within which universities operate, and such systems may at times be intent on maintaining the heteronormative status quo.

We have referred to Uganda's recent ratification of an Anti‐Homosexuality Act (2023), embracing colonial‐era laws that criminalised and pathologised sexual diversity. The act forces doctors, psychologists and researchers to report LGBTQ+ patients to the police, unless the LGBTQ+ person agrees to undergo some form of conversion practice—a pseudo‐therapy that must be administered by a healthcare worker. How then do students and educators respond to these contemporary examples of coloniality, heteronormativity and its intersection with medical education and medical practice? There is an opportunity to develop learner conscientisation by highlighting that the repressive anti‐LGBTQ+ laws recently enacted in Uganda can be analysed through the lens of the colonial history of that country and the legacy of Victorian anti‐sodomy laws imposed during the colonial era. In studying the paradox—the deep roots of sexuality and gender minority‐based discrimination in the ‘enlightened’ West (making the familiar strange) versus the colonial origins of a current repressive anti‐gay/anti‐trans law in a ‘developing’ nation, learner conscientisation can be fostered, and the erasure of histories and experiences of LGBTQ+ discrimination in medical education, in the West, can also be addressed.

Müller and Crawford‐Browne argue that in order to end epistemic violence against LGBT+ people, medical knowledge must be challenged at the source ⁵² :

Changing the structures of knowledge production not only challenges dominant discourses around gender and sexuality, but at best will improve the health care system itself. By educating diversity‐affirming health workers, the system may finally provide adequate care for people whose bodies or identities transgress the dominant paradigm of gender and sexuality.

We cannot challenge structures of knowledge unless we first clarify what these structures look like. Curricular reviews, carefully done, are thus important interventions to identify structural gaps and biases in knowledge production, and dissemination ⁵³ , ⁵⁴ can help to develop standardised curriculum assessment tools to monitor progressive change in medical schools. ⁵⁵ Additionally, simulated consultations between students and trained actors playing LGBTQ+ patients, together with reflexive peer and educator feedback, can help improve (or develop) empathy and diversity‐sensitive communication skills among our future doctors. ⁵⁶ , ⁵⁷ A curriculum and style of teaching that is rooted in empathy is indeed the antithesis of coloniality.

As we work towards an affirmative and transformative pedagogy in the classroom, embracing our own vulnerabilities as educators can be an act of radical decoloniality. If coloniality is about power, authority and control, then decoloniality is about collaboration, reflexivity and egalitarianism. If coloniality teaches us to hate others (and unconsciously hate ourselves), then decoloniality teaches us to love others and love ourselves. Conversations about sexuality and gender in the classroom are not easy because they can defensively trigger our own social, cultural, religious, family and ancestral beliefs and pre‐conceived notions of how bodies must behave. We have all been socialised to think about sexuality and gender in particular ways and undoing this socialisation is not easy and often not desired.

Deliberately holding space for our own vulnerabilities and that of our students may require what Megan Boler calls a pedagogy of discomfort. ⁵⁸ , ⁵⁹ Indeed, working through our vulnerabilities can catalyse scholar activism in our own professional personal development, resulting in what Suntosh Pillay terms ‘vulnerable advantages’ ⁶⁰ —spaces of heightened reflexivity and growth where our perceived vulnerabilities may be our biggest advantages.

As we move towards curricular repair and redesign, we remain hopeful that change is always possible if we constantly sharpen our tools. ⁶¹ , ⁶²

A grounding in how important issues in medicine and medical education have different histories in different global contexts provides much fodder for the development of learner conscientisation in understanding complex multi‐voiced phenomena and in the addressing of potential epistemic violence in curricula.

5. A WAY FORWARD: PEDAGOGIES OF LOVE, CULTURAL SAFETY AND SHARED HUMANITY

In the three perspectives shared in this article, we have posited that:

1. The knowledge systems of medicine are imbued with discriminatory understandings, and that the ‘truths’ presented in teaching in medical education must take this into account.

2. There is an essential need to teach medical care as a rights‐based endeavour, in which the desired skillset is one of cultural safety, as specific ways to address the harms of medicine and health professions education on patients and learners.

3. The inherent coloniality of medical education must be confronted through an examination of interlocking and intersecting forms of oppression and an examination of paradox of context specificity of knowledge.

We have summarised our conceptual framing of the problem of epistemic violence within curricula, as well as how it might be addressed, in Table 1.

TABLE 1.

Conceptual framework for a way forward.

Co‐author perspectives: epistemic violence in medical and health professions education	Educational goals to address the issues	Possible instructional strategies (not exhaustive)
Co‐author 1 (SR): Few opportunities to question the knowledge systems of medicine	Develop learner conscientisation	Narrative competence Engage with critical theories as appropriate to balance the ‘normalising’ pedagogies of professional education Examine the practice and outcomes of health care for structural inequities (structural competence development)
Co‐author 2 (LR): Indigenous erasure Lack of training to provide culturally safe care	Develop learner epistemic humility and respect for non‐Western ways of knowing Valorise and embed the provision of culturally safe rights‐based care into all aspects of training	Exposure to Indigenous ways of knowing Opportunities to examine the epistemological assumptions underlying currently dominant knowledge systems in Western bio‐medicine Teach and model culturally safe care
Co‐author 3 (SP): Medicine as a tool for the propagation of global colonial hierarchies	Develop learner conscientisation An explicit curriculum of shared humanity (Ubuntu)	Learning through examination of paradox: Use global health examples to make the strange familiar (reflect on practice and understanding of a particular issue in a different context or country) and the familiar strange (challenge the assumptions about practice within one's own context or country)

How can medical and health professions educators equip themselves with the tools to mitigate the harms of epistemic violence in curricula in service of greater health equity? To discern a way forward, we suggest that medical curricula seek to develop learner and teacher conscientisation through Freire's pedagogies of love, ⁶³ enacted in a stance of shared humanity, with praxis operating within a culturally safe phronesis.

The end goal of professional learning ought to be the development of skills in critical consciousness as a balance to the normalising pedagogies of professional education. Freire termed this learning process ‘pedagogy of love’. A pedagogy of love is rooted in a regard for learners as conscious beings who, if encouraged to explore and question, will, with the teacher, co‐create understandings of the structures of the world around them that would be greater than if the teacher simply presented the understanding. Such learning occurs in the appreciation of narrative, the interrogation of paradox and the co‐existence of both apparent and deeper meaning for the phenomena of study. Paradox, narrative and deeper meaning abound in medicine, and there is no shortage of material to deepen learner conscientisation.

To give an example, homosexuality was a ‘disease’ in North America until it was removed from the Diagnostic and Statistical Manual of Diseases in 1973. ⁶⁴ This means that it was diagnosed, treated and thought of as having a prognosis and outcomes. Today, we understand homosexuality as simply a part of the mosaic of potential livable lives. Pedagogical opportunities in medical education to examine this, and more current examples of the social construction of disease and health would add much to the development of a critically conscious next generation of physicians.

The development of greater conscientisation through pedagogies of love is an inner process of psychological change, which may lead to difficulty when we consider common issues in medical and health professions education, such as how to assess and measure learning and educational programme outcomes. The external manifestation of learner conscientisation is culturally safe practice, which can be observed and measured, albeit through the experiences of the patient receiving the care rather than the teachers' understandings of what constitutes culturally safe care.

Perhaps the most important educational objective for learners to embody within themselves as practitioners in a curriculum of conscientisation for culturally safe care is that when systems dysfunction, such aswith examples of discrimination or inequity in outcomes, while there is always the agency of specific actors to explain the dysfunction, it is likely that structures are major contributors to it. In other words, if discrimination happens, it is likely not be because of a few ‘bad apples’ but rather because the system is allowing the apples to spoil. Learners must develop the skills to appreciate unjust structures and to commit to using their agency to address parts that need addressing.

Learner and teacher conscientisation will help in the confronting of medicine's inherent colonial nature—how its knowledge systems perpetuate Western dominance, racial hierarchies and ultimately diminished health outcomes for patients from structurally marginalised groups—through curricula that encourage epistemological suppleness to question the inherent injustices baked‐in to the knowledge systems being inculcated within the learner.

If conscientisation is the inner process of change, and culturally safe practice is its external manifestation, then we must define the ethos in which medical curricula are enacted, whether that be in the classroom or at the bedside. We propose that the best ethos to guide the curricular changes required is one that focuses on shared humanity. Our South African co‐author colleague (SP) exposed us to the Bantu philosophy of Ubuntu, ‘I am because we are’, which is widely referenced in his home country of South Africa. ⁶⁵ , ⁶⁶ Professional education rooted in shared humanity seeks to build bridges of solidarity between medicine, the health professions and the people it serves, minimising hierarchies, respecting and seeing value in different ways of knowing and developing stances of humility within learners. The shared and collective humanity perspective of Ubuntu offers us an opportunity to frame medical education as a good of the global collectivity of the profession, with a defined praxis of cultural safety and a pedagogy of love, in service towards excellence in health outcomes for all.

AUTHOR CONTRIBUTIONS

Saleem Razack: Conceptualization; methodology; writing—review and editing; writing—original draft. Lisa Richardson: Methodology; writing—original draft; writing—review and editing; conceptualization. Suntosh R. Pillay: Methodology; writing—original draft; writing—review and editing; conceptualization.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to declare.

ETHICS STATEMENT

This paper did not involve a research protocol with human or animal subjects and institutional ethics approval was not required.

Razack S, Richardson L, Pillay SR. The violence of curriculum: Dismantling systemic racism, colonisation and indigenous erasure within medical education. Med Educ. 2025;59(1):114‐123. doi: 10.1111/medu.15470

DATA AVAILABILITY STATEMENT

Research data are not shared.