Institutional adaptation to the pandemic

The pandemic has disrupted access to and quality of education worldwide, with great variability in the ways academic institutions responded and the accommodations they were and are able or willing to provide students and faculty.36 37 It is imperative to situate that many of these experiences are not exclusive to students of GH. Yet, they are worth exploring within the scope of GHE as they are indicative of how wider global ordering and processes manifest to affect public health trainees and their experiences of the systems they ultimately influence. If equity and justice are central to achieving global ‘health’, should not the GHE industry model these ideals in how it organises and conducts itself?

Across this collective, members felt that accommodations to support student and faculty safety and well-being to adapt to the COVID-19 era (where any were available) were often severely lacking, with significant impact on their physical and mental health. Many students felt as though they had to choose between preserving their health and obtaining their education. Indigenous students felt that they had to unfairly make a choice between their education and kinship vital to the survival of their culture and well-being. Furthermore, one of the coauthors recollected that, in the later stages of the pandemic, their university refused to accommodate students who were unable to attend class in-person despite COVID-19 spikes nationwide, instead suggesting that these students take a leave of absence or withdraw from the university entirely. Other institutions continued education without mask mandates or COVID-19 vaccine requirements, despite formal labour complaints by faculty members.38 39 Frontline healthcare students reported feeling unsafe and afraid to pursue their medical duties, tasks and curricular activities without access to COVID-19 vaccines and adequate protective measures.40 41 Indigenous students felt the dual-burdens of cultural responsibilities at home, such as helping with childcare and going to ceremonies, while attending school virtually, often without accommodations for these cultural obligations.

The shift to virtual learning also imposed barriers on many students and educators who live in areas without adequate tools, such as stable internet or electricity, or who are unfamiliar with emerging technology. For example, Indigenous students that lived on Reservations faced limited access to Wi-Fi as well little to no access to water. While some of these access issues could have been addressed by academic institutions, they consistently were not.

Moreover, because of continuously changing immigration policies and border closures caused by rising COVID-19 numbers and geopolitical power plays, international students were often stranded in their country of study or forced to relocate. In other cases, the pandemic combined with other crises—such as civil unrest, financial collapse and war—deepened the already existing educational divide among students, which also manifested in GHE. While some of these challenges went beyond adaptive capacity or control of academic institutions themselves, they illustrate the impact of complex geopolitical tensions and the politics of GH on access and quality of GHE and training.42 43 Evidently, the disruptions to learning caused by the COVID-19 pandemic do not exist in isolation and one must systematically consider all the factors at play. For existing inequities, the pandemic further exacerbated the issues at hand and demonstrates the necessity of addressing systemic issues within Rreservation borders or within the bounds of sovereign Indigenous Nationhood.

Overall, the conditions members of the group learnt in were dictated by the diversity of tactics their institutions and their nation-states of learning employed to mitigate the pandemic and other crises that evolved over the past 2 years.

Global health education: content and delivery

Although the pandemic emerged as a great example of how local and global social, commercial and political determinants of health drive the practice of public health, several members of this collective felt that the content and delivery of GHE across many institutions had limited success in leveraging external events for internal transformation. By this, we mean that for many members, GHE continued to be largely focused on health ‘somewhere else’, ‘for someone else’ and was predominantly anthropocentric, even as local and planetary health challenges became increasingly severe.44 The pandemic clearly demonstrated that mortality and morbidity of public health priorities (including, but not limited to the opioid epidemic,45 housing crisis,46 poverty and hunger prevalence,47–49 mental health crisis50 51 and climate disasters52 53) are exacerbated by the way in which local contexts are influenced by the current global order (ie, power localised in high-income countries (HICs)) and systems. However, even with the inequity of the world, the focus of many programmes did not evolve to armour us with the knowledge, appetite and/or skills for bottom-up, cross-sectoral, transdisciplinary, community-informed and policy-dynamic that we recognised as critical for positive action beyond the confines of our classrooms. Furthermore, institutions failed, and continue to fail, to recognise Indigenous Nation’s and Indigenous peoples’ rights and to meaningfully incorporate Indigenous peoples’ perspectives and voices into conversations and decision-making processes within the organisations.

Curricula, fieldwork and dissertations in institutions in the Global North still focus largely on public health crises in the Global South. Furthermore, much of the GHE in the Global South aligns (or is made to align) with the epistemic, financial and political powers exerted by institutions in the Global North, whether through ‘global’ standards and frameworks, financial purse strings attached with grants and partnerships or through affiliate-institutions that remain devout to the vision of HIC-based parent institutions. While the incorporation of concepts like equity, justice and oppression into GHE introduced many students into discussions or ideas they did not engage with previously, several students shared that these discussions remained limited to one-off conceptual references in ‘special lectures’ or occasional facilitated dialogue, rather than being weaved into overall GHE course narratives as essential, critical components, which they would have preferred. Often, these discussions also emerged parallel to broader global or national events that threatened equity and justice. Many students described wanting to explore them further in-depth, hoping for a focus on how these concepts can be applied to the praxis and value systems of GH professions locally and globally. Indigenous students explained how they saw the use of the term ‘decolonise global health’ increase in Global North countries during the pandemic, without true engagement and creation of a seat at the decision-making table for members of Indigenous Nations within Global North countries that still suffer the health impacts of colonisation. Various coauthors described feeling as though there was either institutional lack of knowledge and/or awareness, unwillingness, discomfort or at times downright denial and resistance among some educators and colleagues to integrate these topics into their curricula. We encourage candid discussions between GHE institutions, educators and students to explore these tensions further, in an attempt to reimagine GHE to cater to the interests and needs of emerging GH professionals.

Compelling and hopeful exceptions to these trends emerged through the stories of some members, who recounted instances where action-oriented faculty made more structural adaptations to courses. One member highlighted a political analysis of public health course where faculty used various local and global examples to explore how power and privilege manifested throughout the pandemic and incorporated weekly news and headlines that linked to health policy analyses. Another member pointed to a faculty that fundamentally changed the curricula to centre the voices of those traditionally marginalised in global public health discussions. An Indigenous author noted how when their university medical schools partnered with the Oglala Lakota Nation, the author presented a cultural competency training in hopes to prepare the physicians. This helped provide historical context, elevate Indigenous voices and promoted Indigenous-led partnerships, and not just tokenism. From group discussions, it became clear that positive changes in GH curricula in response to calls for reform seemed to be predominantly the result of individual or small groups of action-orientated educators and students willing to commit their time and (unpaid) labour into adapting their courses to ensure a foundation in justice, equity, antiracism, decolonisation and anti-oppression. Systemic and systematic adaptations to GH teaching remain to be fulfilled.

Furthermore, although the shift to virtual learning was accompanied by various challenges, it also provided new opportunities for transnational collaborations and the inclusion of diverse perspectives, knowledge and expertise beyond the dominant HIC-based male voices.54 Guest lectures and collaborative discussions included diverse faculty and students across geographical, professional, disciplinary and demographic backgrounds—including those in close proximity to the issues being taught. GHE thus became more ‘globalised’ in some instances and explored new models to redistribute power and provide a voice to those traditionally marginalised within knowledge systems. These efforts were deemed most effective by coauthors when they addressed inequities in opportunity. For some, education also became more interactive during virtual learning, with increased group discussions and collaboration. Yet, in other instances, a lack of online engagement resulted in a lost sense of social connectedness and belonging prompted by continued social isolation.

Several coauthors reported a change in exam structure from solely memorisation-based questions to those that required more critical thinking. Grading systems were also altered in some institutions to accommodate distance learning. Students mentioned that these changes often increased learning transparency, fairness and consistency. However, such positive impacts were not universally experienced, once again highlighting inequities, with those in higher socio-economic strata often benefiting more from the adaptations compared with other students.55 56

Furthermore, as in-person connection became restricted, virtual connection in informal settings (such as Twitter, Slack, Zoom, etc) became increasingly important. Many members cited that they learned about different ideas about GH such as ‘decolonisation’ from Twitter or informal chats. However, many such discussions and formal conferences, panels, etc remain primarily entrenched in HIC-based networks and circles. Thus, while the locus of power has shifted in some ways, it continues to remain embedded in predominantly elite networks. Another member whose education had been disrupted by both the pandemic and another compounding crisis stated that they learned about GH almost completely outside formal institutions. This group, and others like it, took on new importance because of the conditions of the pandemic. Democratising GHE and facilitating meaningful cross-boundary experiences have ways to go. Yet, change seems possible and pressing.

These positive examples are indeed cause for hope, as they signal that there are ideas and efforts that have demonstrated initial success in making GHE more accessible and relevant to trainees. It also highlights that the absorptive capacity of the GHE industry to scale such efforts needs to urgently increase, so that examples like those mentioned above are not the product of solely individual motivated efforts but can include an overall systematic and systemic effort to re-imagine GH.

Receptivity and resistance to change in global health education and training

Below, we outline some of our experiences engaging with institutional receptivity and resistance to change in GHE. As stated earlier, most examples of receptivity from within institutions came from individually motivated educators and students rallying together to advocate for and push forward dialogue and action around GH transformation.

Across several HIC contexts, the resurgence of the Black Lives Matter movement in 2020 was an important catalyst for a series of critical discussions on change within GH (and to a certain extent in some low-income and middle-income countries (LMICs)).57 58 For instance, while not universally applied, much of the institutional response to police brutality in the USA took the form of diversity, equity and inclusion (DEI) initiatives, or other formal or informal groups of students and educators focused on adapting and transforming curricula to address gaps laid bare by such global and national events. However, in several institutions where students within this collective engaged directly with such efforts, collective members reported that such initiatives often entailed practices that felt ‘safe’ to universities and that did not allow for meaningful structural change, doing little to change-related policy and systemic environments. Despite countless meetings with deans, DEI working groups and antiracist, anticasteist, antisexist (etc) and/or decolonial curriculum development, some group members found limited investment and prioritisation to expand action beyond the maintenance of the status quo. Several students and select faculty were dealing with the responsibility of initiating discussion and redesigning curricula while juggling full-time education, research and/or clinical placement. Paradoxically, while students and staff were stimulated to generate these deliverables, they were often met with ‘soft’ and/or ‘hard’ institutional pushback when the content was considered ‘too radical’ or, more specifically, when the changes proposed necessitated fundamental shifts in how power permeated across the institution’s funding, hiring, teaching and/or outreach activities. For example, one student advocating for integrating concepts around decolonisation and racism into their Global North-based institution was met with denial from the director of the programme, responding that their statement, ‘Global health is rooted in a colonial and racist past’ was too ‘harsh,’ and that there was not evidence to support this claim. Indigenous students attempting to integrate the importance of Global North countries returning land to Indigenous Nations to improve Indigenous health were told not to use the term ‘stolen land’.

While a couple of coauthors reported discussions within LMIC-based institutions around the colonial and discriminatory roots around health(care), most coauthors reported that they would have liked to have explored these topics more deeply, especially in the context of how these roots manifested in their present day lived experiences and the enablers and barriers that facilitate their career trajectory. Many reported turning to social media, other formal and informal groups and collectives, global shifts and local movements and events to get information on such topics. Several coauthors reported local and national movements that shaped the state of health of their communities more broadly, yet these did not always permeate GHE circles and institutions.59–62 At this point, we cannot fully capture why that might be. Against this backdrop, stories of institutional receptivity also emerged: one of the coauthors reported that antimilitary protests and consecutive coups in their country inspired several medical and global/public health institutions to renew and reconsider their accreditation process, an exercise initiated to critically review current curricula, tools and student engagement policies at these schools. Another coauthor reported that anticoup protests in their country63 sparked discussions in academic spaces to strive for education to be inclusive, local and culturally respecting. For one such coauthor, this propagated the creation of a new curriculum led by students in collaboration with faculty in their institution.

In several cases, coauthors noted that even with the best intentions, some efforts fell short, either in investment, content, delivery, institutional knowledge or buy-in from those with the power to exert change, among other reasons. To expand, some coauthors who directly engaged with GHE advocacy efforts in their institutions mentioned that institutional efforts felt ‘superficial’ at times, as for example, institutional leadership did not go beyond media releases, statements, special committees with limited power to materialise change or one-off special lectures or panels in an attempt to address complex, nuanced and contextualised issues. Another student reported that spaces for discussions around colonialism and power discrimination were largely missing from their Global South-based institutions, especially given disruptions due to the pandemic. This limited pertinent discussions around broader global and local issues outside of a predetermined curricula that skewed the view of GH through the lens of the biomedical paradigm.

A few coauthors even noted that they, along with other motivated students and faculty, experienced outright ‘resistance’, ‘dismissal’ or ‘silencing’ when critiques of institution-led and/or faculty-led mission-unaligned actions were raised. The latter point is especially crucial: how are motivated faculty and students expected to continue to push for change when they exist within complex microlevel political contexts that threaten their very progress and survival in this field? This becomes even more salient when recognising the power difference between, for example, a tenure track professor advocating for radical change, and a first-year masters student echoing the same.

Importantly, the combination of bearing the responsibility of encouraging improvements within their GHE, full-time studies, institutional pushback and an impossible threshold for activation energy resulted in negative mental health and burnout among many involved. A few members inside the group stated that they have considered leaving their institution, and GH altogether. Furthermore, burden for change often disproportionately fell onto students and educators that were from historically marginalised and oppressed communities, some of whom struggled with accessibility and affordability of such institutions in the first place.

Yet, many coauthors continue to push for the GHE industry to ‘walk the walk’ in terms of fundamentally incorporating justice and equity into its structures and practices. This can be done, for example, by investing—financially, with human resources, energy, or time—in strengthening specific policies, actions, mechanisms and ultimately the structural environments needed to transform GHE. Such investment is not exclusive to HIC or LMIC institutions—it takes all, across all levels of the GHE industry. LMIC governments, donors and actors need to invest in strengthening the locus of epistemic power in LMICs; invest in and increase the number of quality, accredited and globally visible GH programmes; invest in the educational workforce and more. Similarly, HIC institutions professing commitments to DEI and justice need to fundamentally reimagine the who, what, why and how of institutional leadership, faculty, students and the enabling environment required to set up students for success. Furthermore, several members expressed that intentions or more specifically, commitments made by national, institutional and/or faculty leadership must have mandatory accountability and monitoring mechanisms associated with it, with other ideas including for such efforts to be co-chaired or co-led by representative and democratically elected student-faculty-leadership teams with the ability to exert power when actions do not match intentions.

The pandemic has lifted a smokescreen in GH practice, calling into question various aspects of its existence and praxis. In light of this, we put forth the following questions: How can the global health model achieve its necessary impacts if the field and its training remain embedded within an unequal and unjust global ordering that inhibits many, and frees a few? Are there ways to reconstruct GHE to be more transformative? For our collective, the answer to the latter question included complex multimodal answers, which ultimately tilted in favour of hope. The next section explores our reflections on one potential way to transform the current dominant mode of GHE delivery and engagement.