“Was it really “different back then”?: Reflecting on current global health ethics with a NFB film about CUSO, 1965” , part II

Published on August 31, 2021

Sonya de Laat

Part 1 of this two-part blog introduced the NFB film You Don’t Back Down as a visual narrative case study in global and humanitarian health ethics education at the undergraduate level. Although over half a century old, the film continues to have relevance for students whose sights are set on becoming healthcare providers. Many of the scenes in the film raise ethical issues leading students to questions what has changed since then, thus also revealing historical thinking as a valued component of their future professional practice. Part 2 focuses on the in-class discussions and includes a reflection on the incorporation of visual histories in global health ethics education.

The in-class discussions

When launching into the discussion of the film, invariably students begin by calling out what they consider to be paternalism on the part of the physician. Dr. Alex McMahon is often filmed speaking torather than with—patients, or speaking in a condescending tone: “Why you no go clinic?” He’s also seen speaking as if the patients were not there, when in fact they are right in front of him. This leads to discussions about patient-centred care and the global health principle of humility. 

Other students point out that he does exhibit signs of what we might consider as solidarity or response to sources of inequity when he laments the fact that patients have to pay for healthcare, and that the weak public health system has led to diseases that should not exist, or that he should not have to treat. He was expecting “a utopia of medicine” with no fees. However, he found that that’s not the case in Nigeria, and as he says, “[this] bothers me a lot, but [I] have to accept it ...or the hospital would close...the hospital is performing a great service and it can’t function any other way.” Along with that expression of care, the young doctor convincingly claims, “I like meeting the people, perhaps help them a little, certainly make them more comfortable for a while. And, heavens, sometimes medicine can’t do much more than that.”

At the outset of the film, Dr. McMahon states that his motivation for going to Nigeria was to, “work in a country that was newly developed.” Students interpret this as a sign of a lack of interest in contributing to strengthening the country’s healthcare system, prioritizing instead the opportunity to “challenge his training” in a way not possible in a highly specialized practice context in Canada. This raises philosophical questions among students about instrumentalism, on the one hand, and altruism, on the other. Students also then consider more practical aspects of these types of international opportunities that appear to be missing in this CUSO example such as capacity building, mutual learning, and shared benefits.

Some students consider Alex’s stated fear that he may have to perform a surgery he has never done before as potentially unethical, as practicing outside his skills. Others see it as courageous—and necessary—given that it appears there is no one else skilled to do it (though we know little about the skills of his colleague from Scotland or of the local staff). This concern of the young doctor raises questions about responsibilities. The fact that he and his European colleague have between them only five years of experience further raises the question of responsibility. Should aid organisations be sending such novice healthcare providers to such an underserviced area? What would happen if a situation were to emerge that is beyond the skills of the two physicians? Where can these healthcare providers get support, materially and psychologically? At one point Dr. McMahon admits to, “Sometimes working so much I am sick, I get over my head.” This risk (or realization) of reaching a limit point is reinforced as likely as explained by the narrator who describes the situation faced by Dr. McMahon as one “plagued by poor equipment, lack of funds, [and] bewildered patients.”

Image 1 31 August

All images in this blog are screen shots from the film “You Don’t Back Down,” included by permission of the NFB.

Ethical dimensions of the filmmaking aspects are also discussed in class. A persistent colonialist mentality—or at least a sense of superiority—is reinforced by the opening narrative in which the location is introduced with men in dugout canoes. The voiceover presents a romantic vision of an emerging new nation, yet still condescendingly described as a “West African backwater”, a sort of wild frontier “just beginning to feel itch of modernity.” The introduction is rendered contradictory however by the repeated appearance on screen of fully modern people with motorcycles and dressed in the height of 1960s fashion.

 Image 2 - 31 August  Image 3 31 August

Despite the appearances, local residents are literally related as backgrounds in the film, adding “colour” with song, dance and crowds. They have no voice; none speak on film like the McMahon’s. On top of that, other foreign healthcare providers in the film are named, but not the local nurses. By extension, students also point out professional hierarchies, ones that appear to also intersect with racial or other social status discriminations (e.g., age, class). For instance, a Canadian nurse featured in the film is treated more as a colleague than the younger, local nurses who are at times patronized and even lambasted.

 Image 4 31 August

A further means of reinforcing western/northern superiority, the film’s narrator introduces the babies from the leper colony next door to the McMahon‘s home, with the claim, “Kept separate from their diseased parents, the children are better cared for than most, and will probably grow up to be part of a well educated minority and perhaps even become members of the establishment.” Such a statement quite paternalistically suggests that Nigerians are not capable of raising ‘successful’ citizens, regardless of being affected by a debilitating illness or not.

There is, of course, also a long time spent with the students discussing patient consent, and what informed consent means when being filmed while a patient. For example, a young-adult female patient is filmed in her hospital bed, topless. The healthcare providers and filmmakers obviously consider this a normal and acceptable scene. Class discussion here gets into criticism of perpetuation of racial tropes versus justifications along the lines of cultural relativism including different concepts of privacy or propriety. It is usually at a point such as this in the classroom discussion that a student says, as if to justify the ethically questionable aspects of the film: “it was different back then”, which leads to the pinnacle of the lesson. 

I suspect this type of statement emerges because the student(s) are sympathetic to the culture shock and the challenges the McMahon’s faced. What such a statement risks doing (or is possibly hoped to be done, on the part of the student) is to shut down discussion. My response to that statement invariably is, “was it very different back then?” This is where the discussion gets exciting, as it is the place in the lesson where students realize something they may not have observed before: the present-day relevance of the content depicted in this vintage film. 

In preparing for these discussions, I lean on the ideas of Andrews and Burke and their 5-C’s of historical thinking to add to the discussions (see also, historicalthinking.ca for a Canadian project on critical historical literacy). According to Andrews and Burke (2007), the “five C's do not encompass the universe of historical thinking, yet they do provide a remarkably useful tool for helping students at practically any level learn how to formulate and support arguments based on primary sources, as well as to understand and challenge historical interpretations related in secondary sources.” I find their formulation particularly helpful in introducing the value of applying historical knowledge and perspectives in current contexts.

One of the 5-C’s particularly relevant the film discussion is “Change over time”. In today’s medical practice—at least as likely to be practiced by these Canadian students—there is greater emphasis on patient-centred care. As gets pointed in the discussion that ensues, this approach can result in ethical dilemmas when working within different cultural contexts.

Another of the 5-C’s is continuity, which is possibly what surprises students the most when considering the film’s content. Generally, we would like to think we have learned, grown and changed for the better from “back then”, but many of the ethically questionable elements represented in the film continue still today. For instance, many inexperienced healthcare practitioners still participate in short term overseas medical experiences, which itself is a point of ethical debate, but also is recognized as contributing to turnover and the high rate of providers not returning for subsequent overseas work. Recently, attempts have been made to mitigate this by having shorter trips abroad, say for six months, especially for those who are new to this type of work.

Tellingly, Doctors Without Borders (or MSF, by their French acronym) made an almost updated version of You Don’t Back Down with their 2008 film, Living in Emergency. At times almost a scene for scene recreation of the NFB film, the recent film follows—among others—a young doctor sent to work in a remote area facing rare and advanced ailments, and a lack of resources or supports. Indeed, the neophyte physician even expresses similar fears as McMahon of not being able to do what he knows he could do in better resourced area, and feeling overwhelmed and unsupported. The classroom discussion about continuity of conditions and experiences leads to important discussions about the ideals of global health and humanitarian practice versus the reality. Sometimes, the discussion begins to take on the form of a debate about what organizations’ priorities should be or should include, for instance responsiveness to causes of inequities and commitment to the future. Coincidentally, a similar debate was occurring within CUSO around the time of the NFB film too (Brouwer 2013)

There is also a provocative theory I lean on from visual theorist and philosopher of photography Ariella Azoulay: what she calls “potential histories (2013).” For Azoulay, this idea means returning as close as possible to the situation in which the camera was present in order to reconstruct the event, and—more importantly—the perspectives of those who were involved. It is a means of acknowledging different hopes and expectations in that moment, and thus potential directions and decisions that could have happened. 

Applying her ideas can lead to provocative thought exercises. What might we have learned had we heard from the people who are otherwise silent in the film? Would we have heard criticism about the inexperience of the doctor? Perhaps they were grateful to have anyone with more skill. Were they expectant that there would have been formal capacity building taking place as they continued towards full independence?

Furthermore, with potential histories, it is important to note that McMahon never returned to CUSO, or Nigeria, or on any other overseas medical experience after this two-year trip. What might have happened if his first stay was shorter? We do not know if this is because he was dissatisfied with the direction CUSO was going in, or was it because he felt unsupported, or was he left morally conflicted and unable to properly manage what he experienced? We may never know; Dr MacMahon died in 2015 after a full and—by all accounts—successful career as a physician in western Canada.

Potential histories may seem like speculation and easily lead to anachronism, but this type of thought exercise, or political imagination play, is beneficial especially if it helps restore underrepresented perspectives, and helps think more nuanced about the present. 

Concluding reflections

As a form of public engagement with history, incorporating You Don’t Back Down in an undergraduate ethics lesson as a visual case study allows learners to both be introduced to past humanitarian and development aid work, and to the value of thinking historically in the present. For learners focused on their future career goals, the aim of the ethics lesson is to provide a rich narrative helpful for grappling with complex ethical quandaries that continue to resurface in overseas aid work, while also providing historical perspective necessary for developing culturally and contextually relevant interventions. Certainly, it was ‘different back then’, but how different and in what ways the actions of the past still impact aid and healthcare relations today are relevant, even urgent, points of discussion. 

Indeed, as a member of the audience to the CHA panel that this blog post is based asked: What are the ethics of history? In this current moment of decolonization and anti-racism, learning different histories takes on the appearance of a moral imperative for aid workers. As humanitarian organizations and providers show more interest in self-reflexivity and the histories of the profession and their beneficiaries (as evidenced by the ’sold-out’ Aga Khan Foundation of Canada’s hosted panel on histories of Canadian aid), there is no better time than the present to engage with the past for a more just and equitable future.

References for Part 2:

Andrews, T. and Burke, F. (2007). What does it mean to think historically? Perspectives on History: The newsmagazine of the American Historical Association. 1 January.  https://www.historians.org/publications-and-directories/perspectives-on-history/january-2007/what-does-it-mean-to-think-historically

Azoulay, A. (2013). Potential history: thinking through violence. Critical Inquiry, 39(3), 548-574.

Brouwer, R. C. (2013). Canada's Global Villagers: CUSO in Development, 1961-86. UBC Press.

SonyaSonya de Laat is a scholar of visual culture related to humanitarian action, global health and international development. She is the Global Health graduate academic advisor and a sessional lecturer at McMaster University. She is also an active member of the Canadian Network on Humanitarian History housed at Carleton U and an investigator with the Humanitarian Health Ethics research group based at McMaster and McGill universities. She is interested in the role of visuals—particularly photography—in histories of moral and practical dimensions of aid. Recognizing limitations inherent in the medium, Dr. de Laat’s work draws attention to the potential in photography to draw attention to ways in which we can secure a more equitable and compassionate world. Recent publications include “The camera and the Red Cross: ‘Lamentable pictures’ and conflict photography bring into focus an international movement, 1855–1865” (2021) in the International Review of the Red Cross“Pictures in Development: The Canadian International Development Agency’s Photo Library” in The Samaritan State Revisited (2019) and “Seeing Refugees: Using Old Photographs to Gain New Perspectives on Refugees, Past and Present” (2018) available on ActiveHistory.ca

 

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