Lessons on accompaniment: November edition of the Decolonising Global Health series

About the authors:

Debbie 'Dada' Dada is a PhD student in Public Health and Implementation Science at Washington University in St. Louis whose research focuses on participatory implementation science and global health justice.

Anne Neumann is a research associate and medical student at Charité - University Medicine Berlin where she works on leveraging qualitative methods in multidisciplinary projects concerning health equity issues.

Anne and Dada recently completed the MSc in Translational Health Sciences at Oxford University.

A friend of ours recently shared her experience training as a junior doctor on a palliative care ward. Amidst the busyness and scarcity of clinical practice in many specialties, she was struck by how end-of-life care demanded something different: patience, sitting (sometimes even in silence) and listening. Listening not just to hunt for clinical clues, but to experience a part of a patient’s world with them; to learn of their relationships, their notions of home and their priorities in care decisions. Her experience of offering dignity to those who are dying by being present, attentive and even tender within chaotic hospital walls made us reflect on how we engage with others in our global health work. The concept of accompaniment, first introduced by global health pioneer and physician Paul Farmer, prompts us to pay attention to how we walk alongside others in global health research and practice. In this piece we reflect on three aspects of accompaniment and what they might teach us about working against the colonial legacies and structures of global health.

Accompaniment involves sharing life with those experiencing the brunt of structural violence; committing to understanding the historical, political and social structures driving their oppression; and working alongside them in struggling against such structures while mitigating the negative impact. Accompaniment is a practice and ethic that grew out of Farmer’s early work in Haiti, where community health workers (called 'accompagnateurs' in the organisation he co-founded) were trained to not only deliver care but also walk with patients through the ups and downs of illness and ordinary life. It has since been applied to questions of justice in how we organise care, create policy and direct funding. Farmer describes accompaniment as 'being present on a journey with someone,' not to lead or to rescue, but 'sticking with a task until it’s deemed completed by the person or people being accompanied.'

Community health workers walking alongside individuals, families and communities through illness and day-to-day life help us see accompaniment in action.

First, accompaniment invites us to share life, spend time and cultivate real friendships with those experiencing the forms of structural violence we work against. Depending on one’s positionality, this often requires some measure of integration into another’s world. When we practice accompaniment, we stand in solidarity not only with abstract ‘underserved populations’ but with real individuals with names, histories, aspirations, fears and humor. At times, in critical global health spaces, we can find ourselves so consumed by our passion for dismantling violent systems that we lose sight of the real people who drive us. Accompaniment reminds us that our goal not only goes beyond ending oppression rooted in coloniality but also includes walking together towards co-liberation in ways that uphold dignity, warmth and hope.

Second, accompaniment calls for commitment to understanding the structures that create and sustain oppression. This commitment centres listening as a receptive and humbling practice. Becoming more proximate with those positioned differently in dominant social political structures also means growing distant from the vantage points with which we have grown familiar. Listening enables new realisations that lead to discontent with the systems that provide for one’s privileges and another’s suffering. That is, an estrangement within current systems shared with those harmed by structural violence. Through building a systematic yet personal understanding of marginalising structures, accompaniment therefore nourishes the discontent that drives decolonisation movements in global health. It is important to note, however, this understanding cannot erase the distance that Dr Seye Abimbola critiques as all-too-common in global health practice. All may share in the estrangement but do not inhabit it in the same way. When we walk with each other and develop a shared understanding of oppressive structures, we see each other as equal in our humanness; however, we need to recognise and work with the persisting differences between us. 

Third, accompaniment prompts us to struggle together. Decolonising movements do well to focus on enacting high-level structural change in decision-making within governments and powerful global health institutions. These efforts have brought about important shifts in funding priorities and research agendas that are more responsive to the needs and leadership of affected communities. At the same time, accompaniment pushes us to work alongside communities engaged in grassroots social action for better conditions that promote social, health and economic rights. After all, these local movements are often the ones sustaining pressure on the governments and institutions to follow through on commitments for change. In this way, accompaniment reminds us that the decolonisation project requires both structural and collective action.

The seemingly ordinary act of sitting with someone at the end of their life can help us see the importance of paying attention to how we walk with others in our decolonising global health mission. Accompaniment invites real relationship, committed learning and engagement in a collective struggle. As our friend’s stories invited us to reconsider the personal and vulnerable in our work, we invite you to ask yourself: how might you engage in accompaniment through your work?