Abstract: There is a strong need for the humanities and arts in global health training and research. However, the relationship must move beyond the instrumental use of humanities content and arts-based training methods towards a balanced, interdisciplinary collaboration. What is/could be the role of theatre in teaching global health practitioners? This paper describes how reading, rehearsing and performing Deborah Laufer’s play, Informed Consent, affected student learning in a global health ethics course. We demonstrate improved student metacognition and evidence of emerging communities of practice and argue for increased collaboration between theatre practitioners and global health educators.
Keywords: Active and experiential learning, global health ethics education, metacognition, communities of practice, Playwright Deborah Laufer, Informed Consent
Introduction and Background
Decades of work in the medical humanities confirms that a focus on story, voice and metaphor invites physician reflection on patient stories, thereby increasing physician empathy for, and trust with, their patient (Charon 2001). Theatre, particularly improvisation, can also improve physician-patient communication through more effective problem solving, decision making and collaboration (Watson 2011).
In response to the often instrumental appropriation of the humanities and arts as mere training tools for biomedical physicians, the new perspective of critical medical humanities broadens both the field of medical humanities and the practice of narrative medicine to incorporate non-Western biomedical settings and the pursuit of social justice in medical education. Global health, one of the fastest growing segments of medical education in the US, Canada and Europe (Merson and Page 2009), is just beginning to explore the value of the humanities and arts for its curriculum and research. Should global health programs mimic the ways in which the arts and humanities were introduced into medical education in the US and UK?
Unlike biomedicine’s dyadic relationship between physician and patient, global health is focused on population health. Therefore, one-on-one interactions between non-clinically trained global health practitioners and the community are more likely to occur in the context of research rather than patient care and treatment. Most global health programs are located in, or closely aligned with, schools of medicine or public health. And even when an undergraduate global health program is housed in an arts and sciences division, its teaching faculty are more likely to come from medicine, public health and quantitative social sciences, such as psychology or biocultural anthropology, and less likely to represent the interpretive social sciences or humanities; they almost never come from the performing arts, such as theatre studies.
We argue that while there is a strong need for the humanities and arts in global health, the relationship must go beyond an uncritical and instrumental incorporation of humanities content and arts-based training methods in global health. This paper is framed by several questions: What is the role of the humanities and arts in educating global health practitioners and is it a mirror image of how we deploy the humanities in medical education in the US? What is/could be the role of theatre in teaching global health practitioners about their research methods as well as their community engagement strategies? Can theatre improve undergraduate global health ethics education? How does reading, rehearsing and performing a play affect student learning of an ethics assignment? What is the value of the performance after the student leaves the classroom?
We addressed these questions in fall 2017, in collaboration with 27 Duke University students enrolled in the undergraduate course, Ethics of Infectious Disease Control, one of several ethics courses offered for global health majors. The course is designed to help undergraduate students develop knowledge of, and skills related to, ethical analysis in global health through case studies about research ethics that arise primarily in the control of infectious disease. A standard approach in ethics education is to challenge students to identify and debate multiple ethical perspectives in a single case study. Our more ambitious goal was to push students to engage, and even empathize, with conflicts not merely between multiple stakeholders, but contradictory positions held by a single stakeholder.
We searched the literature on critical medical and health humanities for innovative pedagogical techniques to improve research ethics education for global health students. In addition, we drew on two specific bodies of work in theatre studies, Paulo Freire and Augusto Boal, plus the techniques of applied theatre as deployed by NGOs to promote community action and individual health behavior change, for example, with HIV/AIDS education in Africa.
As a result of that collaborative and interdisciplinary exploration, the teaching team developed a course enhancement exercise that required all students in Stewart’s fall 2017 course to participate in a public reading of the award-winning play, Informed Consent, by Deborah Laufer.
The play is based on the true story of research misconduct by Arizona State University researchers working, between 1989-2003, with the Havasupai, a Native American tribe who have lived in the bottom of the Grand Canyon for centuries. The play was a New York Times critic’s pick in 2015. Since Stewart already taught the Havasupai case as part of the course, the play seemed uniquely tailored to enhance course content. In addition, the play provided a rich and diverse range of characters for students to embody as they grappled with the implications of genetic technologies that revealed more about our future, and our past, than our current value systems have answers for. How much should we know about ourselves? About others? Who gets to do this research and what do they owe the research participants? Is it ever okay to mislead a research participant? What is the value of belief when it conflicts with science? Is DNA destiny? These key ethical questions had been discussed in previous semesters and appeared on exams. Engaging these questions by requiring non-theatre studies undergraduates to participate in a staged performance offered a novel opportunity to assess the depth of student learning. We publicized the performance through both a flyer and a two-minute promotional video clip.
The use of theatre is especially innovative for a global health ethics course. We deployed theatre’s active and experiential pedagogies to increase student capacity for affective learning and critical thinking in the context of medical research and clinical practices, specifically highlighting multiple, contradictory, and often irreconcilable points of view. The ability to choose one action as the correct action, despite contradictions, is at the heart of ethical reasoning. How does reading a script, in contrast to academic writing, reveal a clearer path towards ethical action? Are students more compassionate, more empathetic and more creative in their ethical analyses after embodying a case study instead of just reading and writing about it? Could performing a script about an actual ethical case strengthen student retention of complex information? To answer these questions, we collected observational data about student interactions during rehearsals, compared answers on the same quiz before and after the performance, analyzed student reflections written during the final exam and studied the post-performance talkback transcript. But before that, the Director, Nehanda Loiseau, had to direct.
“How many of you are performers?” I announced this question while gesturing to my actors now in front of me. No one raised their hands at first; then, one slowly rose in the middle of the room. This spurred me to characterize theatre as a perceived outsider, one belonging outside of their ethics classroom. We discussed how performance seemed to exist in its own space, but how aspects of it underlie our day-to-day lives: our interactions with others, interior monologues, hidden subtext when speaking and our specific backstories inform each of these choices. I asked the question again to my class of 27 students and raised my hand with them.
Although hired as Director of the theatre module that took up the last third of the fall 2017 semester, I considered myself student number 28. I would show up alongside others who were as curious as I was about how this process would unfold, and, most importantly, how the performance could come together after only three weeks and six 75-minute class sessions/rehearsals. Yet, six weeks later, when I read their final exam reflection essays, I discovered, instead, that they were apprehensive and even shocked to learn they would be required to participate in a staged reading of a play in front of an audience. Indeed, I did not realize that those 27 students were the brave remnants of an initial group of 42 students who were enrolled on the first day of the semester; one in three students dropped the course as soon as they heard the professor speak the phrase: you will perform in a play.
I felt my own discomfort, too, not yet knowing these students, and for being responsible for transforming them into characters from another place (the American Southwest), embroiled in a strange and offensive episode that unfolded two decades earlier. To direct the class, I pulled from a toolkit of performance techniques I learned as a theatre practitioner. Below, I describe three of these techniques, while weaving in relevant data (student essay responses) to illustrate how these techniques may or may not have impacted them. Consider the techniques shared below in conversation with other fields unrelated to theatre, as they were with ethics. Consider, too, how one can “act” in other realms.
Technique 1: Start with Why
If our expectation is to have theatre translate to non-theatre fields, then the reverse should also be the case: other fields can influence theatre. With this technique, I tapped into Simon Sinek’s “Golden Circle” of a successful business: convincing consumers of the “why” of your company, its purpose. Knowing the “why” guarantees a more profound story that ripples from the first product or service purchase to many.
I “started with why” with our students. During introductions on the first day of the theatre module, I asked my new actors to tell me their name, year and why they are studying what they are studying. The answers went as far as “to dismantle institutional racism” and “to inspire young girls who look like me.” I wanted to set the stage for a level of self-reflection that went beyond the surface. The hope was that this, in turn, would translate to seeing their character roles beyond simply hero and villain. Why did they make the choices they made? Why do we? At one point did these “whys” intersect? One student wrote on the final exam:
What surprised me the most was how much I connected with Jillian [protagonist]. She was technically the “bad guy” of the play, so I didn’t expect to relate to her a lot. But as an “overachieving” Duke student, I kind of understood that thirst for knowledge and the passion/big dreams that she possessed, as well as the fixation with “rationality.” I felt the emotions she was feeling, particularly with trying to save Natalie [Jillian’s daughter], even though I did not have those experiences.
Technique 2: Art as Ethical Practice
According to social anthropologist Jonas Tinius, performance is an ethical practice in which “rehearsals emerge as both spaces and practices of self-conduct” (2017). His ethnographic fieldwork was spent with the German ensemble theatre troupe, Theatre an der Ruhr. This troupe’s process from script to stage delves deeply into the decisions of each of the characters they perform: from thoughts to dialogue to physical behaviors. In Tinius’ study of der Ruhr’s techniques, he argues that theatre is a portal through which everyday ethical stances are communicated. What we believe (and of course “why” we believe it) determines how we act. We make choices and communicate those choices through our words, gestures, and interactions with characters and objects both onstage and off. Our moral code is embodied daily. During one rehearsal, we tested this theory with the following role-playing activity:
I distributed index cards to students stating a character to portray during an imaginary cocktail party. I cued the music and let the mingling begin. One student cowered in a corner the entire time Nina Simone serenaded us through the speakers. Although that student’s card read “terrified of strangers,” the room was shared with a nun, a political activist, a former Broadway star, someone who wished they were somewhere else and another whose card stipulated: “you shy away from alcohol, but you’re the bartender tonight.”
During that rehearsal, most students reflected their moral code by displaying one particular action (such as, cowering in a corner). In choosing one clear action, most students were following the assigned reading materials and lectures on the Havasupai case, which emphasized that while most of the stakeholders depicted their own ethical decision-making as a stark decision between right or wrong. But, within the world of the play, some students understood the nuances of characters, their complex motivations and even ambivalent actions. One student wrote:
When we study these types of cases, it’s easy to distance ourselves and think, “I would NEVER do that!” But reading the play reminded me that we’re all human and prone to making mistakes. Simply reading ethics cases doesn’t make you immune from crossing ethical boundaries.
Technique 3: Breaking the Fourth Wall
The script for Informed Consent emphasized blurring the actor/audience border, so I found it necessary to define for the class the concept of the “fourth wall,” the invisible wall separating audience from actors on stage. I explained the effectiveness of breaking this boundary. If the audience is not simply a “voyeur” of the theatrical experience (Fouché 1976: 106), then, there are ways they can actively participate in the story and moments when the audience and actors can actually exchange roles. In performance, we broke another wall, the one separating the staged reading and the student’s campus reality. Before the script’s first words were read during the public performance, students entered the stage as if they were entering their global health ethics classroom on any given day. “Class” was the stage, and where their professor normally stood, was the audience. As students/actors they would perform, teach and be heard, but they too would also listen to their audience/teachers in the post-show discussion:
Interestingly, I found that the most meaningful part of the performance process for me was not, as Nehanda says, acting and making ethical decisions in action, but, instead, the talk back afterwards where I was able to field questions from the audience that had just watched the play and from peers who had just participated.
One student went from student to teacher during the talkback:
I was having proud teacher moments when my classmates were answering questions by using different frameworks or ideas that we talked about in class.
Borders and walls separating reality and performance disappeared prior to the staged reading and after it ended. In the dressing room before the show, a student described a discussion that centered on experiences during summer service abroad:
Students casually talked about their experiences while others rebutted with ethical questions and qualms about engagement in other countries. For me, this indicates the level of permeation the class reached into our everyday lives because of the commonality of the theatre module.
Students also shared their engagement with peers not enrolled in the class:
I was surprised by how lovely a discussion I had about the case with my friends, and how my views on the characters’ actions were so different [than those of my friends].
Here’s to the day when there is no need to “transition” to a theatre unit within a global health class, and a play is not tucked away waiting to be revealed, sparking with it shock, apprehension and discomfort. Perhaps the true revelation is not what theatre can do, but what it is already doing. But that we just simply have not raised our hands yet to call it performance.
Pedagogical Analysis: What Worked?
From the individual student responses quoted above, it is clear that studying and reading the script prompted meaningful reflection by the students on both their experience of performance and their knowledge of the ethics of the Havasupai case. Their reflections seem to confirm our hypothesis that deep learning and understanding is enhanced by embodying stakeholders/characters in a public reading of a play that conveys factual information through character story arcs. Students seemed more compassionate, more empathetic and more creative in their written ethical analyses after performing a case study than merely reading and writing about it. But exactly how did the pedagogical innovation enhance student learning? What were the strongest gains in the student experience? And how could we enhance student learning even further?
We asked a two-part question: what is the impact on student learning of supplementing the standard classroom approach to ethics education (lectures, academic materials, exams) through (1) studying a play about an ethics case study and (2) performing (reading) that play in a public venue? We gathered three types of data: pre- and post- assessment of the theatre intervention, open-ended reflection essays written as a final exam and a transcript of the thirty-minute post-performance talkback session with students, playwright Deborah Laufer, the teaching team and 100 audience members.
Outcomes were assessed through two analytic frameworks: student metacognition and evidence of the emergence of a new community of practice. Metacognition, simply defined, is student awareness of their own learning. Building on studies in the 1980s of child cognitive development (Baker and Brown 1984; Flavell 1985), the National Academy of Sciences released their 2000 landmark study, “How People Learn,” which highlighted metacognition as a foundation of effective instruction for adults. Metacognitive practices increase student awareness of themselves as learners, therefore enhancing self-awareness of their strengths and weaknesses, and increasing their ability to transfer or adapt their learning to new settings. A community of practice, as developed by Etienne and Beverly Wenger-Trayner in the 1990s, is a group of people “who share a concern or passion for something they do and learn how to do it better as they interact regularly.” Because a key indicator of successful ethics education is the transference of individual student learning into the collaborative environments of a research team or community setting, we looked for evidence of students applying their ethics training beyond answering exam questions.
We found clear evidence that studying the play as a course reading assignment increased student breadth and depth of knowledge, and resulted in better retention of information and more nuanced awareness of the multiple perspectives held by the stakeholders/characters in the play. However, performing the play seemed to foster deeper types of learning, and promoted advances in student metacognition and the formation of incipient communities of practice. These impacts clustered around four categories: self, others, knowledge/awareness and action/change.
For example, metacognitive gains at the first intersection of self and knowledge/awareness were reported as increased awareness of the limitations of factual knowledge about the case, a surprised appreciation for how performance encouraged learning through the embodiment of the emotion of the characters and an awareness of the value of the different types of learning styles they saw amongst their peers. Metacognitive gains at the second intersection of self and action/change were the awareness that this new knowledge will stay with them long after the class is completed, attempts to apply their new understandings of different learning styles in other class settings, explicit statements about committing to be a different, more ethical type of scientist, as well as a reported confidence about their ability to teach the case to other research collaborators outside the classroom.
We also found suggestive, but encouraging, evidence of the impact on student learning of performing the play as measured through the concept of communities of practice. Because ethical research unfolds in conversation with others, the communities of practice framework captures elements of this collaboration just as a theatrical unit captures its central methods by putting them in action in the preparation and presentation of the play’s reading. In our particular learning setting, evidence of the development of a successful community of practice would be a shift in the learning nexus from instructor-student to student-student, plus a clear uptake by students of practice-based and socially embedded learning.
At the third intersection of others and knowledge/awareness, students reported observing classmates learning and changing through the performance, having increased empathy for others—especially their classmates who struggled with performing, and a deeper appreciation for the complex motivation of the characters in the play. Finally, at the fourth intersection of others and action/change, students reported new and authentic friendships with their classmates, experiencing true collaboration for the first time in the classroom, feeling supported by the unity of purpose in the class and being inspired to have exciting ethics-based conversations with non-classmate friends outside class. These features are consistent with improved ethics education.
We achieved much in student learning, but to ease anxiety about the public performance, in the future we will devote more time to presenting a basic introduction to performance and schedule more rehearsal time. In terms of benefits to global health ethics education, we confirmed the value of theatre as a pedagogical innovation to improve student learning. Beyond that, we also see signs that the formal structure of studying and delivering a public reading of a script is likely more beneficial for global health trainees than other types of performance used in medical education, such as improv. We would argue that the scripted repetition and evolving camaraderie of rehearsal is closer to the inter-personal dynamics of a research team and holds more value for global health trainees than the unscripted, spontaneous nature of improv. The success of the public event (100 attendees) also raised the profile of both theatre as a teaching tool, and the value of collaboration with theatre studies faculty, amongst the global health faculty at Duke. In fact, our collaboration was selected by the Duke Global Health Institute as one of the “Top Ten” global health stories of 2017. But what of the value for theatre studies faculty? Our hope is the data presented here could be leveraged by theatre studies faculty as an entrée for approaching other faculty across the campus to jumpstart new conversations and productive partnerships.
 Laufer spent several days at Duke University as an artist-in-residence in Fall 2017, attended rehearsals and participated in the post-performance talkback with over 100 audience members. Funding for Laufer’s campus visit, plus other production costs, was generously provided by the Duke University Health Humanities Lab and the Franklin Humanities Institute.
 The Center for Teaching at Vanderbilt University hosts an excellent website of resources related to metacognition for university teaching and learning
 See their website for a wealth of up-to-date resources on communities of practice
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*Kearsley A. Stewart, PhD, is Professor of the Practice at Duke University with joint appointments in the Duke Global Health Institute and Cultural Anthropology. Stewart’s current research interests include research ethics of HIV/AIDS clinical trials in Africa, global health pedagogy, and global health humanities. She currently teaches both graduate and undergraduate courses in global health research ethics, ethics of infectious disease, narrative methods in HIV/AIDS research and qualitative global health research methods. She is Co-Director of the Duke Health Humanities Lab and faculty associate with the Trent Center for Bioethics, Humanities and History of Medicine.
ORCID iD: https://orcid.org/0000-0002-9624-9956
**Nehanda Loiseau is a Creative Content Specialist at Arts Alliance Illinois, whose mission is to promote statewide civic engagement, arts education and cultural equity for Illinois’ creative sector. Prior to returning to her native state, she was a full-time graduate student and theatre practitioner at Duke University. Along with her role as director of Informed Consent, she produced a theatre festival at Duke centered on the theme of borders (“Border Story Fest: the Dominican Republic and Haiti”). Her research has entailed the use of theatre in mental health care and “performance” as a critique of humanitarianism. She has guest lectured theatre courses at UNC Chapel Hill and is currently co-editing an anthology of performance pieces by women writers on the theme of “home” with lighting designer and retired UNC professor, Kathy A. Perkins. She holds an MBA from NYU and is a newfound fan of impact investing in the arts industry.
***Jules Odendahl-James is professional director and dramaturg specializing in art+science collaborations, documentary performance and works by women playwrights. At Duke, she is a lecturer in Theater Studies, the Program Director of Arts and Humanities Advising, a member of the Disability Access Initiative, the Reimagining Medicine faculty and a 2017-18 Teaching for Equity Fellow. Her work has appeared in the journals Theater Topics and Crime Media Culture, as well as the collections Violence in American Culture, The Routledge Companion to Dramaturgy and forthcoming in Physical Dramaturgy. In 2016-17, she was a Kienle Scholar of Medical Humanities at Penn State College of Medicine and collaborated with students in her “Medical Stories on Stage” course on an adaptation of MK Czerwiec’s (Comic Nurse) graphic memoir Taking Turns: Stories from HIV/AIDS Care Unit 271. Her current book project is Over My Dead Body: Anatomizing the Forensic Imagination on Stage, Page, and Screen.
****Crissi Rainer recently graduated from Duke University with an MSc in Global Health. She is currently pursuing a career in HIV focused research. Crissi’s MSc thesis examined the acceptability and feasibility of a novel HIV testing strategy in children and adolescents in Harare, Zimbabwe. Before attending Duke University, Crissi served as a Teach for America Corps Member and taught middle school science in High Point, North Carolina. Additionally, Crissi has over ten years of experience in healthcare as a Nuclear Medicine Technologist.
*****Evi Alexopoulos is a Duke University sophomore majoring in Biology and Global Health with a concentration in Emerging Infectious Diseases. This summer, she will be interning in New York City for Project Achieve, an HIV vaccine trials program. Evi met Professor Stewart through her course, Global Narratives of Living with HIV/AIDS, and has been a work-study student with her since fall 2017. This fall, she will be studying abroad in Copenhagen, Denmark, where her core course of study is Health Delivery and Prioritization in Scandinavia.
Copyright © 2018 Kearsley A. Stewart, Nehanda Loiseau, Jules Odendahl-James, Crissi Rainer, Evi Alexopoulos
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