Online Brazilian Journal of Nursing | ISSN: 1676-4285

Escola de Enfermagem Aurora de Afonso Costa – UFF

Dr. Celestino Street, 74 – Downtown, ZIP Code: 24020-091 – Niterói, RJ, Brazil.

Email: objn.cme@id.uff.br | Website: http://objn.uff.br/

REFLECTION ARTICLE

Ubuntu in health education: a reflection on decolonial education as a tool for antiracist resistance

Débora de Souza Santos1, Patricia Lima Ferreira Santa Rosa1,2, Gabriela Rodrigues Bragagnollo1, Andrea Ayvazian3, Giovanne Bento Paulino1, Bruno Pereira da Silva1, Diego Santiago Montandon1

1 Faculdade de Enfermagem da Universidade Estadual de Campinas, Campinas, São Paulo, Brasil.

2 Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil.

3 University of Massachusetts, School of Public Health & Health Sciences, Amherst, Massachusetts, United States of America.

RESUMO

Objective: To reflect on the importance of antiracist education in training health care workers, drawing on the principles of Ubuntu philosophy and a decolonial perspective. The goal is to promote an inclusive academic environment and more equitable health care services. Method: This reflective article explores the concept of Ubuntu, emphasizing its focus on interdependence and valuing diversity. It then addresses structural racism in Brazil and its impacts on the health of the Black population, highlighting the need for antiracist strategies and the integration of intersectional approaches to social determinants of health. The text argues for the relevance of incorporating a decolonial perspective into health curricula, challenging hegemonic narratives and reclaiming historically marginalized knowledge. Examples of antiracist pedagogical practices developed by educators committed to promoting racial equity are presented. Conclusion: Antiracist education is crucial in training health care workers because it fosters critical reflection on racial inequalities and contributes to building a more inclusive health care system that addresses the needs of historically marginalized populations.

Descriptors: Black Population; Ethnic Minority Health; Health Workforce Training.

INTRODUCTION

Ubuntu is an African philosophy that emphasizes the interdependence and connection among human beings. Derived from Bantu languages, the term ubuntu means “I am because we are,” which encapsulates the essence of shared humanity(1). This principle recognizes that individuality is deeply tied to collectivity and that one person’s well-being is directly linked to the well-being of all. Ubuntu values compassion, respect, dignity, and solidarity, challenging the individualistic and competitive notions predominant in Western societies(2).

Within this context, it is crucial to understand that racial issues are deeply intertwined with Brazil’s history and social structure. Addressing the complexity of racism and its impact on health education requires exploring concepts and perspectives that reveal the dynamics and challenges faced by Afro-descendant populations and health care workers. Data from the Brazilian Institute of Geography and Statistics (IBGE) indicate that, in 2022, the Black population (Black and Brown individuals) accounted for 56.6% of Brazil’s population, totaling approximately 120 million people(3).

We begin this reflection by contextualizing the concept of race, as addressed by thinkers such as Sueli Carneiro and Lélia Gonzalez. For them, “race is not merely a biological category but a social construct that permeates relationships and power structures, shaping individual and collective experiences”(4). In the Brazilian context, it is essential to recognize the persistence of structural racism. As Silvio de Almeida states, “racism is a consequence of the very social structure, that is, of the ‘normal’ way in which political, economic, legal, and even familial relations were formed”(5).

Statistical data make the consequences of structural racism clear. According to the Brazilian Institute of Geography and Statistics (IBGE), in 2022, 33.8% of the Black population lived in poverty, compared to 15.2% of the White population(6). The prison system presents equally concerning figures: according to the National Penitentiary Department (DEPEN), in 2022, 66.5% of Brazil’s prison population consisted of Black individuals(7). In the health care sector, the indicators are alarming. In 2021, the maternal mortality rate among Black women was 57.9 per 100,000 live births, compared to 34.1 among White women(8). Additionally, the neonatal mortality rate for Black children was 11.2 per 1,000 live births, while for White children, it was 7.6(9).

In the field of education, in 2022, only 34.6% of the Black population aged 25 or older had completed high school, compared to 61.4% of the White population(9). In health care, according to the Brazilian Federal Nursing Council (COFEN), in 2021, 28.6% of nursing professionals were Black, yet only 15.9% held leadership positions(10). Regarding the training of health care workers, IBGE data indicate that in 2022, only 7.5% of physicians and 12.4% of nutritionists were Black(6). This underrepresentation highlights the urgent need for affirmative policies and actions to promote racial equity both in education and in the health care workforce.

Thus, the aim of this reflection is to analyze the importance of antiracist education in the training of health care workers. This analysis is grounded in the principles of Ubuntu philosophy and a decolonial perspective, seeking to foster an inclusive academic environment and promote fairer, more equitable health care delivery.

METHOD

This work is a reflection grounded in the decolonial perspective as advocated by Grada Kilomba and Kabengele Munanga, aiming to build antiracist education within health training. It begins with the recognition of the coloniality of knowledge and power. As Munanga states, “it is essential to denaturalize hierarchies and promote critical reflection on the structures that perpetuate racism”(11).

Furthermore, Foucault’s theories on biopower and Achille Mbembe’s concept of necropolitics provide a framework for understanding how “health policies can become instruments of control and violence against Black bodies”(12). This approach highlights the urgent need to question and challenge the systems that oppress Black lives.

Thus, guided by the principles of Ubuntu philosophy, this reflection examines the racism embedded in health education, the challenges of implementing antiracist education, the importance of intersectionality and social determinants of health, as well as examples of resistance and transformative actions led by Black professionals. The goal is to broaden the discussion on building a more inclusive and equitable health care system that acknowledges institutional racism and develops strategies for resistance and reparation.

Structural racism in health education

By drawing from African ancestral traditions, Ubuntu emerges as a response to contemporary challenges in health education, offering pathways to develop antiracist education. In a world marked by complexity, this philosophy invites us to reflect on our interconnectedness and mutual responsibility(1). We propose Ubuntu as a living, transformative practice, aligning it with decolonial education in pursuit of a more just and equitable future.

Ubuntu stands out as more than solidarity or communalism; it embodies a profound understanding of the interconnectedness and interdependence among individuals and communities. Valuing diversity and respecting human dignity are fundamental pillars for building a just society(2).

In this text, Ubuntu serves as a guide for antiracist education, providing an ethical foundation to deconstruct colonial structures and promote racial equity, particularly in health education. Decolonial education challenges hegemonic narratives, questions privilege, and values historically marginalized knowledge.

Jurema Werneck(13) highlights the contributions of social movements to the Health Reform and the creation of the Unified Health System (SUS), ensuring significant achievements. The Zumbi dos Palmares March, held in 1995, spurred the creation of the Interministerial Working Group for the Appreciation of the Black Population, which led to the inclusion of the race/color category in the Live Births Declaration. Popular movements have been instrumental in addressing racism in health care, culminating in the establishment of the National Policy for the Comprehensive Health of the Black Population (PNSIPN) in 2009.

This State Policy(14) provides revealing data on racial health disparities. The proportion of medical consultations by race/color is 74.8% for White individuals, 69.5% for Black individuals, and 67.8% for Brown individuals—all below the national average of 71.2%. Between 2007 and 2021, the HIV infection rate was higher among Black individuals (51.7%) compared to White individuals (39.4%)(15). Additionally, the policy highlights that 60% of Brazilian women aged 50 to 69 underwent mammograms in the past two years. Of these, 66.2% were White, and 80.9% had completed higher education, whereas the worst indicators were observed among Black women and those with lower levels of education. These findings, presented in the PNSIPN, align with other studies, such as “Racism and racial inequity in self-rated poor health: The role of intergenerational social mobility in the ELSA-Brazil Study” and “Institutional racism in universities and its consequences for Black students’ lives: A mixed-methods study.” Both studies link the health indicators of the Black population to institutional racism in health care. Whether due to barriers to access, intersections of gender, class, and education, or other challenges, racism persists within institutions, perpetuating health inequities(16-17).

A pathway outlined by the PNSIPN(14) and researchers in the field to address health inequities is investing in antiracist education for health care workers. While the inclusion of Afro-Brazilian and African history and culture in elementary and high school curricula is mandated by Law No. 10,639/2003 and extended to higher education through National Education Council (CNE) Resolution No. 1/2004, specific challenges remain in the health care sector. In this context, the National Curriculum Guidelines for the Education of Ethnic-Racial Relations and for the Teaching of Afro-Brazilian and African History and Culture (DCNERER) and the PNSIPN complement one another by proposing antiracist training for health care workers. Both emphasize the need to construct curricular frameworks that address ethnic-racial relations as well as Afro-Brazilian and African history and culture. The goal is to train critical professionals who can understand the specific needs of the Black population and act in an equitable and inclusive manner.

In response to this need, the Brazilian Association of Collective Health (Abrasco) established Thematic Group (GT) 28, titled “Health, curriculum, training: experiences, learnings, and resistance on race, ethnicity, gender, and their (dis)affections.” This group is connected to the GT on Racism and Health(18).

Despite the laws and guidelines emphasizing the importance of teaching about racial health inequities, there is still a lack of actions and initiatives that effectively promote antiracist training in the field. The existing initiatives, identified by researchers from the GT on Racism and Health, are often the result of direct collaboration between researchers and targeted strategies. Notable among these efforts are the Specialization Course on Black Women's Health, developed by the Graduate Program in Health and Environment at the Federal University of Maranhão (UFMA), and the Research Methodology in Black Population Health course, offered by the São Paulo State Department of Health in partnership with the Population Studies Center (Nepo) at the State University of Campinas (Unicamp). Additionally, workshops conducted as part of the Health with Culture program represent significant progress in this direction(18).

Thus, the scarcity of initiatives aimed at building antiracist education remains a significant obstacle to dismantling practices that perpetuate inequalities(4). It is urgent to ensure the incorporation and strengthening of epistemologies, research, and actions that value and recover knowledge sensitive to racial issues, particularly in the context of health education. This is essential to prepare workers capable of providing care that aligns with the specific needs and realities of the Black population, which is largely marginalized by the health care system(13).

In this context, discussing the challenges and prospects of antiracist education in health training becomes an urgent necessity. As an initial step in this process, it is essential to adopt decolonial thinking as a critical and transformative approach(19). From this perspective, Lélia Gonzalez(20) suggests that it is possible to question the power and knowledge structures that have historically marginalized and silenced the voices and experiences of Afro-descendant communities. This opens pathways to building a more inclusive education system, firmly committed to racial equity.

Challenges and prospects in antiracist education

The lack of targeted education addressing the health needs of the Black population highlights a significant gap in the mandatory curricula of undergraduate health programs. This shortcoming results in the training of professionals without the essential competencies to care for a community that represents over 50% of Brazil’s population(21). Although the National Curriculum Guidelines (DCNs) establish principles for ethical, humanistic, and generalist training and emphasize addressing regional health needs and strengthening the SUS(22-23), the effective implementation of these guidelines faces considerable challenges.

In this context, institutions responsible for training health care workers are called upon to adopt a stronger ethical and social commitment in developing their Pedagogical Projects. It is essential that these projects align more effectively with the needs of the population served by the SUS. The Black population, which constitutes the majority and often faces more vulnerable epidemiological conditions, in addition to enduring historical processes of social oppression, requires health care that considers its specificities and challenges(13).

However, it is crucial to recognize that state policies and practices often reflect colonial dynamics, perpetuating structures of marginalization and exclusion(11). Overcoming this legacy requires an approach that opposes colonial imperialism in health education(21). This involves rethinking curricula and educational practices, challenging dominant discourses, and creating spaces for intercultural dialogue. Valuing the knowledge and experiences of marginalized communities is essential, adopting a decolonial sociopolitical stance to combat racism in health education.

It is essential to emphasize that structural racism manifests through institutional, historical, cultural, and interpersonal practices that systematically advantage one group over another(5). In health care, this dynamic results in poorer living conditions and reduced access to social goods for the Black population, alongside the institutionalization of racism within the sector. This fosters a scenario of greater exclusion, neglect, and institutional violence(13).

Professional practice must prioritize life by integrating technical and scientific knowledge with cultural competence and sensitivity. Providing effective and meaningful care to the Black population requires recognizing differences and addressing them with equity.

The intentional inclusion of racial topics in the curricula for training health care workers—at the undergraduate, continuing education, and postgraduate levels—as well as in the agenda for permanent education, is an urgent necessity(11). However, simply incorporating these topics is not enough; curricula must deepen knowledge on intersectionality. By considering the interconnections between race, gender, social class, and other dimensions, health care workers will be better equipped to provide sensitive and effective care, acknowledging the diversity and complexity of human experiences(13).

Integrating an intersectional perspective into health curricula goes beyond being a matter of social justice; it also aligns with the Sustainable Development Goals (SDGs)(24) and Ubuntu philosophy. By emphasizing interdependence and solidarity, Ubuntu reminds us that the collective can only fully thrive when each individual is recognized in their entirety, free from discrimination or exclusion(2).

Social determinants of health and intersectionality: deepening the recognition of racism in health care

The reflections under discussion highlight that institutional racism within the health care system is a tangible manifestation of racial health disparities. These inequalities stem from power structures deeply rooted in discriminatory practices, shaping a reality that demands a critical and transformative approach.

In this context, it is essential to explore the importance of antiracist education for health care workers, drawing on theoretical frameworks such as intersectionality, as proposed by Kimberlé Crenshaw(25), and the social determinants of health, as outlined by scholars like Sir Michael Marmot and Paulo Buss.

Intersectionality invites us to examine multiple dimensions of humanity (e.g., race, gender identity, sexual orientation, special needs, and economic status) through a critical lens on power relations. In health care, this approach reveals how racism intertwines with other forms of oppression, affecting both health outcomes and access to care.

Traditional approaches based on social determinants of health, while important, often fail to capture the complexity of inequalities. These determinants, though crucial, frequently fall short in adequately addressing the interactions between various forms of oppression and their manifestations in the health care field(25-26).

Social determinants of health, such as income, education, access to services, and working conditions, are fundamental for understanding health disparities. However, these approaches often oversimplify the complexity of experiences lived by marginalized groups, including Black individuals, women, and members of the LGBTQIAPN+ community(13).

Intersectionality reminds us that health experiences are shaped by the interaction of multiple social determinants. It emphasizes that race does not operate in isolation as a determinant but intertwines with gender, social class, and sexuality(27). Racism not only increases the risk of specific diseases but also perpetuates structural health inequalities. Therefore, it is essential that approaches to social determinants of health recognize and incorporate the intersectionality of experiences, addressing how racism and other forms of discrimination exacerbate disparities and impact both access to and quality of care.

In Brazil, Black intellectuals provide significant and diverse contributions, fostering critical reflections on the Black woman’s experience within the unique context of Brazilian racism. This racism, shaped by symbolic and structural whitening processes and the myth of racial democracy, deepens inequalities. Lélia Gonzalez(20) explores the intersections of sexism, racism, labor, and other forms of oppression, asserting that racism, as a foundational element of Brazilian culture, intensifies the other oppressions faced by Black women. The anthropologist exemplifies this entanglement of oppressions by critiquing the societal divisions and stigmas imposed on Black women, who are often portrayed either as sensual bodies or as “black mothers”/caregivers/domestic workers. These stereotypes diminish their humanity, reinforcing positions of objectification, subordination, and invisibility.

In this context, while advocating for the SUS and its principles of universality, comprehensiveness, and equity, Werneck(13) emphasizes that recognizing intersectionality enables the identification and analysis of the unique characteristics of each group. This recognition facilitates the development of conceptual and methodological tools better suited to the diverse contexts and experiences of oppression faced by the most vulnerable groups.

Antiracist education for health care workers must therefore adopt an intersectional approach, acknowledging the complexities of patients’ identities and the intersections between various forms of discrimination.

This requires a critical analysis of the power structures that perpetuate institutional racism, as well as reflection on the privileges and biases of health care workers themselves. To achieve this, it is essential that education addresses the structural roots of racial disparities in health, fostering a critical understanding of the policies and practices that sustain institutional racism. This approach demands a deep examination of the power dynamics shaping the health care system, alongside the development of strategies aimed at promoting equity and social justice.

Incorporating concepts such as intersectionality and advancing decolonial and antiracist educational practices in health care training paves the way for transformative change. These approaches empower professionals to identify and confront health inequities, while inspiring training practices aligned with the principles of Ubuntu.

The next section explores innovative practices that promote racial equity in health education. Through inspiring experiences committed to building a more just and inclusive health care system, valuable lessons can be drawn to advance antiracist education. This proposal, in harmony with Ubuntu philosophy, highlights solidarity and human interdependence as fundamental pillars.

Mapping antiracist resistance actions in health care

The reflections presented thus far reveal a challenging scenario. To highlight effective initiatives, this section aims to showcase promising results through inspiring examples. These are decolonial and antiracist educational practices led by professionals committed to transforming health education in Brazil. Such actions represent significant strides toward more equitable and inclusive training.

At the forefront of initiatives promoting antiracist education in health care are professionals demonstrating the feasibility of innovative practices in higher education. A notable example is Dr. Suiane Costa Ferreira, a professor in the Nursing program at the Universidade do Estado da Bahia (UNEB). She leads the course “Relações Étnico-Raciais e o Cuidado em Saúde” and organized the book Debate Contracolonial na Formação em Saúde: Resgatando a Ciência de Kemet(21). In this work, Dr. Ferreira and her team share their successful experience introducing a counter-colonial and Afrocentric perspective into the academic environment.

Also in the state of Bahia, Professor Dr. Bárbara Carine Soares Pinheiro stands out. A chemist, philosopher, and faculty member at the Institute of Chemistry at the Federal University of Bahia (UFBA), her work transcends disciplines. Although she does not work directly in health care, her bestselling book Como ser um educador antirracista(28) addresses critical topics with interdisciplinary and interprofessional applications. In her book, she explores themes such as the role of white educators in the antiracist struggle, strategies to confront racism in educational settings, diversity, and affirmative action policies. Additionally, Bárbara manages an Instagram page titled Uma Intelectual Diferentona, which has garnered over 440,000 followers(29).

In the state of São Paulo, other notable initiatives stand out. At the University of São Paulo (USP)—the last Brazilian university to adopt an affirmative action policy—the School of Medicine hosts the research group Race.id, which focuses on the health of the Black population. This group is led by Dr. Ana Claudia Camargo Gonçalves Germani and Dr. Júlio Cesar de Oliveira, both physicians. Race.id was created in response to the needs of Black medical students, who often felt out of place in a university environment disconnected from their ethnic-racial, cultural, and socioeconomic experiences. Currently interdisciplinary, the group carries out impactful initiatives, such as offering the elective course Formação do profissional de saúde e combate ao racismo(30). Additionally, the group develops clinical scenarios where racism is considered a component of diagnosis, utilizing the OSCE (Objective Structured Clinical Examination) method. This approach fosters a more inclusive training environment that is sensitive to racial issues.

At Unicamp, an innovative and progressive context has emerged, highlighted by the work of Professor Dr. Débora de Souza Santos, a Black nurse and faculty member at the School of Nursing, deeply engaged in the antiracist struggle within professional training. Among her initiatives is the annual postgraduate course Políticas e práticas de saúde com foco na diversidade étnico-racial, de gênero e de orientação sexual(31). This course reflects her commitment to inclusion and equity in health education. Additionally, Dr. Débora developed, based on her habilitation thesis, a theory of antiracist education called The 4 Rs of Antiracist Education. This framework is built on the principles of Recognize, Resist, Repair, and Rebuild, offering a powerful theoretical structure for transformative educational practices.

Thus, “Break” refers to an ideological rupture with the hegemonic, Eurocentric, patriarchal, and racist scientific order, which disregards the knowledge and cultures of peoples from the Global South, historically shaped by colonization and the genocidal exploitation of slavery. It also involves breaking away from epistemes that produce and reproduce domination relationships, justified and normalized by institutions rooted in structural mechanisms of oppression such as racism, sexism, and ageism. “Recognize” involves identifying the social inequities produced and reproduced by the hegemonic order, intersected by markers such as class, race, gender, and sexual identity. It also requires acknowledging the strengths of oppressed peoples, including their memories and ancestral knowledge, which have been systematically erased and silenced. “Resist” encompasses actions to challenge the status quo, as well as political, cultural, and community organizing strategies that promote empowerment, political engagement, self-care, support, and quilombo-building. These initiatives strengthen oppressed groups in their fight against forms of oppression. Finally, “Repair” or “Rebuild” involves implementing concrete actions at both micro- and macro-political levels. These actions aim to establish more equitable relationships among vulnerable or minority groups, driving structural changes to ensure access to universal human rights with equity.

Professor Dr. Débora also coordinates the Curso Ubuntu - Vivência Educacional Multirracial: Diversidade, Equidade e Inclusão na Saúde, conducted in partnership with Dr. Andrea Ayvazian, a biologist and nurse from UMass Amherst in the United States. The course, designed for groups of up to 30 students, is facilitated by faculty and facilitators who are often former participants. Its activities focus on the educational experience of students from diverse ethnic and racial backgrounds, utilizing the Multi Racial Unity Living Experience (MRULE) methodology and Culture Circles. These approaches are grounded in the framework of the 4 Rs theory.

With a total of 36 hours dedicated to antiracist education, the course is conducted over two weeks during Unicamp recess. Sessions are held in small groups, aiming to foster the exchange of experiences, raise awareness of racial and social issues, spark critical consciousness, and strengthen both individual and collective capacities to confront oppressions such as racism, sexism, and LGBTQIAPN+phobia.

These initiatives, predominantly led by Black individuals, play a crucial role in advancing antiracist education. By implementing measures that recognize and combat racism in health education, these actions demonstrate an ethical, political, and legal commitment to Brazilian society. They contribute directly to social justice and the development of a more inclusive, equitable, and diverse health care system.

CONCLUSION

Incorporating antiracist education into the training of health care workers, rooted in the principles of Ubuntu philosophy and the decolonial perspective, is essential. There is an urgent need to recognize and address structural racism in health care facilities as well as to adopt intersectional approaches to social determinants of health to combat racial inequalities.

The analyses presented herein offer significant contributions to the field of antiracist education in health care, highlighting innovative training practices led by educators committed to transforming the health care system. These initiatives underscore the importance of integrating a decolonial perspective into curricula, challenging hegemonic narratives, and reclaiming historically marginalized knowledge.

To promote racial equity in the training and professional practice of health care workers, additional research is necessary to explore effective strategies for implementing antiracist curricula and to develop evaluation mechanisms that measure the impact of these practices on the quality of care provided to Black populations.

Strengthening interinstitutional and interdisciplinary partnerships, both nationally and internationally, is also recommended. Such collaborations should involve educators, researchers, health care workers, and social movements, aiming to build a more inclusive and equitable health care system.

Finally, it is crucial to ensure the continuous engagement of educational institutions and government agencies in implementing policies and actions focused on eliminating institutional racism and promoting social justice in health care. After all, the principle “I am because we are” shines brightly in educational practices that foster cooperation in health training.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

FUNDING

This paper was carried out with the support of the Coordination for the Improvement of Higher Education Personnel (CAPES). Process No. 88887.744334/2022-00.

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Submission: 21-Jun-2024

Approved: 03-Nov-2024

Editors:

Ana Carla Dantas Cavalcanti (ORCID: 0000-0003-3531-4694)

Paula Vanessa Peclat Flores (ORCID: 0000-0002-9726-5229)

Edlamar Kátia Adamy (ORCID: 0000-0002-8490-0334)

Corresponding author: Bruno Pereira da Silva (Email: bruno.silva@ufac.br)