You can take the girl out of the community, but you can't take the community out of the girl

It is truth universally acknowledged that one is the product of one’s environment, and as OTs we know ‘environments’ are far more than just physical. Where we live, who we are surrounded by, and what experiences we have lived through all shape our perception of the world. At a community level, understanding the origin of positionality of individuals and the community at large, becomes essential to understanding their goals, opinions and ways of life. As healthcare workers, understanding how our own positionality may differ from those who live in the community we work and why this is so, bridges a divide that could have potentially broken the therapeutic relationship. But this is all far easier said than done. Introspection is tough. 

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Working at a community level is more than just an eye-opening experience, it’s a revolutionary one. As South Africans we’ve become numb to poverty and all the factors that contribute to it. These issues are discussed around middle-class tables like my own, with a sigh, a shrug and the turn of the newspaper page. Why? Because they are viewed as someone else’s problems. Other and external. As inhumane as this may be, we are all guilty of similar thoughts, myself included. It’s a result of big city life- a petri dish of egocentric and capitalistic values. Whether at home or school, someone is encouraging you to compare yourself to someone else and come out on top. For me, it began with sibling rivalry. Then at school level, sinister forces have us comparing our marks and rating our own worth via academic or sporting accomplishments, always having some form of ‘winner’ and ‘loser’. The reality is, as a white middle-class South African I see the world through my white-middle-class-South-African tinted glasses (punny- because I literally wear tinted glasses). However, I work in a community where my white- middle-class-South-African approach won’t work. Firstly, because I practice in a low-income community that is predominantly made up of cultures that differ from my own. Secondly, because the entire white-middle-class-South-African mentality of “every problem can be solved with a bit of effort” is out of touch here- and has been for far more than 26 years. Therefore, community level work is a revolutionary one. It pokes holes in your own positionality and demands that you change your approach- immediately- at both at a personal level and a systemic level. 

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The revolution has begun with an interrogation into my own thoughts, and by placing the systemic operations of healthcare practices on trial. Healthcare itself has a positionality in South Africa. There has been a shift towards a more socialist model of healthcare with the implementation of the NHI, a direct reflection of the positionality of our government. This will shape the way that health professionals are being trained and what services we provide. It will also have an impact on our professional identity, which is why many private practice healthcare professionals feel threatened, as there is a great deal of personal content with the current capitalistic model (we’re an egocentric society after all). Governmental positionality is also seen through partnerships made with countries such as China, who have provided us with PPE during the pandemic, as well as our ongoing medical partnership with Cuba. This has roots in anti-Apartheid efforts attempting to encourage development in the South and combat Western hegemony (Hammett, 2007). Our profession’s positionality is that of holistic care and client-centred practice. The institution I study under, emphasises community-centred practice and partnerships with the DOH. Therefore, the State itself, the institution that moulds me, the Council I practice under, and my own personal upbringing, will all shape my professional identity. 

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There are both big-picture and home-grown influences on the minds of health professionals. In their commentary about personal identity as medical doctors, Fergus, Teale, Sivapragasam, Mesina, & Stergiopoulos (2018) note that our individual positionalities as well as the positionality of the institutions we have studied under have influenced our professional identity. They go on to emphasise that there must be efforts made to empower medical students to integrate their pre-medical backgrounds when developing professional identity, so as to develop empathetic professionals (Fergus, Teale, Sivapragasam, Mesina, & Stergiopoulos, 2018). As noble as this concept may be, I believe it would apply mostly to professionals with a background as minorities and marginalised groups- who could go on to create positive and empowering experiences when working with similar groups. The opposite is actually required of professionals from a privileged background, such as mine, where our positionalities are out-of-touch with the communities we serve. In my case, I need to apply backwards chaining to the thoughts of Fergus, Teale, Sivapragasam, Mesina, & Stergiopoulos (2018), and dismantle my pre-professional background and biases in order to empathise with those whom I serve. The challenge then becomes, how do I recognise my own influences on a client’s treatment and when does this become an issue? 

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The community I work in, is in stark contrast to the one I live in. The people are different. The ways to pass time are different. The work is different. If I were to come into this community with my own positionality at the forefront, and blind to the perspectives of those who actually live in the community- I would be no better than a coloniser. We all know that that doesn’t end well. Not only would this result in giving people what they don’t need or want (ahem-flavoured condoms https://theconversation.com/south-africa-is-rebranding-its-condom-campaign-will-it-work-this-time-45027-ahem), but it would also result in zero sustainability of any programmes we start. That being said, it’s not easy to put aside my own positionality and keep my work clear of all external influence. It creeps up on me. I see it in the way I question my clients about their background (did you matriculate?), the way I prioritise my life analysis (do you work?), and even the way I do my health promotion (when last did you go for a check-up?). My own positionality is influencing how I determine “problem-areas” and what I would prioritise in treatment. For me, meeting a single-mother automatically has me seeking support structures, because my personal upbringing was from a 2-parent home. For me, being unemployed is a problem that requires intervention, for others it is an acceptable status and not the be-all-end-all. I’ve noted that in the fast-paced community-level practice, my own positionality heavily influences goal-setting and framing of the client’s context, as my knee-jerk responses are direct implications of my own positionality. For example, a homeless client that I spent an hour with last week, did not prioritise his relationship with his daughter above his need to search for work- but I did. My own personal positionality, where support and family are the foundations to a healthy life, heavily influenced my approach to treatment. I may not have done harm, but these are small actions that can lead to clients not wanting to continue therapy, as they may feel that their needs are not being understood. 

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To combat this, Marcelin, Siraj, Victor, Kotadia, & Maldonado (2019) propose the strategies of deliberative reflection, active questioning and mentorship. Essentially, this is what we’re asked to do twice a block through evaluating our clinical performance. In order to grow as a therapist, this interrogation of my own actions needs to happen more often and without an Excel spreadsheet. As a student, I tend to shy away from having my peers evaluate my work, it’s a consequence of cut-throat academic-focused schooling, but overcoming this and getting peer feedback on my work may be one way to ensure my positionality doesn’t skew my treatment plans. More so than the personal impact that we can have as individual healthcare workers, is the large-scale impact our actions can have on an entire community. The projects we initiate have the potential to change lives and influence young minds. Therefore, it is imperative that we go into communities wanting to understand their needs and collaborating, collaborating, collaborating. If not, we risk setting unrealistic expectations, handing out empty promises, and ensuring that everything goes back to the status-quo as soon as our backs are turned. Every project or programme that we initiate needs to include a few representatives from the community, thereby giving us that incredibly important feedback and active questioning that could save us from ourselves. By doing this, we actually save resources (yaaay!), but this is a step that I often overlook (damn) because my brain tells me I know better (double damn). A prime example of positionality skewing project implementation has arisen from the now infamous medical scooter project (https://www.iol.co.za/news/politics/r10m-eastern-cape-medical-scooter-project-is-a-fail-reveals-health-minister-50707971). Here, we see how a genuine need for primary healthcare services resulted in a R10 million payday and still the community’s urgent needs are not being met. As students, we sometimes lean towards quick fixes because they’re easy and we’re slightly more concerned about our own well-being (mostly, sleep) than that of the community. Again, it’s a failure to look past our own needs and that egocentric voice inside our heads, and it needs to be actively fought. 

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Yes, introspection is tough. No one enjoys picking apart their actions or acknowledging shortcomings. However, there’s no hiding from the influence of our own positionality on our work, and thus, we need to understand our own inner-workings to ensure we’re not allowing our personal perspective to influence our professional actions. I don’t believe I can ever be free of the influence of my own positionality on my work; however, I can become more conscious of it. It’s a tough process, but not an impossible one. Accountability, reflection and feedback are daily actions that we can take as students which may have a profound positive impact on the way we practice; all that is required is for us to acknowledge that we aren’t perfect. 

References: 

Fergus, K. B., Teale, B., Sivapragasam, M., Mesina, O., & Stergiopoulos, E. (2018). Medical students are not blank slates: Positionality and curriculum interact to develop professional identity. Perspectives on medical education, 7(1), 5-7. 

Hammett, D. (2007). Cuban intervention in South African health care service provision. Journal of Southern African Studies, 33(1), 63-81. 

Makinana, A. (2020, July, 9). Wheels fall off EC scooter project - 'Do not meet basic criteria to be used as ambulances': Zweli Mkhize. Sunday Times. Retrieved from https://www.timeslive.co.za/politics/2020-07-09-wheels-fall-off-ec-scooter-project-do-not-meet-basic-criteria-to-be-used-as-ambulances-zweli-mkhize/. 

Marcelin, J. R., Siraj, D. S., Victor, R., Kotadia, S., & Maldonado, Y. A. (2019). The impact of unconscious bias in healthcare: how to recognize and mitigate it. The Journal of infectious diseases, 220(Supplement_2), S62-S73.

Penfold, E. (2015, July, 27). South Africa is rebranding its condom campaign: will it work this time? The Conversation. Retrieved from https://theconversation.com/south-africa-is-rebranding-its-condom-campaign-will-it-work-this-time-45027.