Dr. Maxwell Kennel

Senior Research Associate at the Dr. Gilles Arcand Centre for Health Equity, Northern Ontario School of Medicine University

Lecture Text: What is Social Accountability? (January 2024)

Given the energy around Social Accountability at ICAM 2024 in Vancouver, below I have posted the slightly edited text of a lecture I gave in the NOSM University Human Sciences Seminar Series this past January, the recording of which is also available here.

1. INTRODUCTION

Social Accountability plays a significant role in guiding health professional education as well as institutional health policy strategy across the globe. We know that Social Accountability is a principle taught in medical schools that urges health professionals to respond to the needs of society, but the concept is also in need of clarification – especially as it relates to social justice and EDI.[1]

Below, my hope is to enrich the conceptual and philosophical basis of Social Accountability by deconstructing our preconceptions about it and then reconstructing it using some resources from the Humanities and Social Sciences. The argument behind the argument I make today, is that Social Accountability needs philosophy – not the philosophy that takes refuge in abstraction or represents the patronizing superiority of the ivory tower, but the vein of philosophy that asks deep and incisive questions about the good life, the human condition, and the nature of justice, while being rigorously held to account to the discourses on these topics that have been underway for over 2000 years.

I notice that everyone who I talk to about Social Accountability is a secret philosopher, and I have yet to encounter someone in the conversation on the topic who does not see Social Accountability as something to be defined, contested, debated, valued, or even condemned – each of which are highly philosophical activities that, of course, have real linkages to everyday life, both personal and professional.

I will begin by situating myself and stating that my way into this exciting topic is through my work here at NOSM University. For almost two years now, I have worked with Erin Cameron and the rest of the team at what was the Centre for Social Accountability, and what is now called the Dr. Gilles Arcand Centre for Health Equity. Before moving to Thunder Bay, I defended my dissertation in the Religious Studies Department at McMaster University, and then completed a SSHRC Postdoctoral Fellowship at the University of Toronto. My training is in philosophy, theology, social history, and most of all the scholarly study of religion and society, all under the banner of the Social Sciences and Humanities. In and through these disciplines, I focus on two paradigms that I use as lenses to examine complex texts in the history of religious and philosophical thought and keywords like violence, postsecularity, conspiracy, and accountability: the first lens is called Critical Theory and the second is called Political Theology. I will begin by outlining both paradigms, and then proceed to connect them to Social Accountability below.

Lens #1. Critical Theory[2] is a discourse that comes out of a specific group of intellectuals in postwar Germany (often called the Frankfurt School), and it focuses on how we criticize the normative foundations of our societies and communities. Good critical theory will show how there are commonly used ideas that we assume are normal, natural, and neutral, but which are really normative, meaning that they are values we make and perpetuate through our decisions. Critical theory attempts to show how even the most natural-seeming ideas about the human condition are a result of power and decision, in ways that could always be otherwise, if only we collectively decided otherwise. For example, we may think that it’s only natural that human beings are self-interested subjects who act competitively to maximize profit. But critical theorists are at pains to show how this way of thinking about the human condition is anything but natural, but instead reflects very specific and very damaging trends in intellectual history and power politics.

So, that is the first paradigm I work with. The second is called Political Theology.

Lens #2. Political Theology[3] focuses on the place of religion within secular modern societies. Through its lens I look at how many of our ideas and practices retain a religious form, even when they appear to have no religious content. Good political theology reveals how the ideas that we use have long and storied histories that entangle both religious and secular influences. For example, both our positive idea of “progress” and our negative idea of “apocalypse” are structured by specific ways of thinking about time and history that come from Jewish messianism and Christian ideas about the end of time. Even when we appeal to technological or economic progress, or when we think about climate apocalypse or an apocalyptic novel, religious ideas are informing how we think underneath the surface. For better and for worse, without religion, it’s unlikely we would think the same way about how time and history might build toward a conclusion, and this applies to many other cultural keywords as well.

So you may be wondering: What can a scholar of religion and social critique say about this very specific topic in medical education? This study is my answer to these questions, because within it I will be making a case for a new perspective on that fundamental value within medical education, and I will do so by looking upstream to the preconceptions that cause us to expect and seek Social Accountability in the first place. This is key, for it is part of the methodological approach in much of the Humanities and Social Sciences to consider the conditions that make certain ideas and practices thinkable and possible.

To illustrate what I’m trying to do, I want to take a moment to think about the Social Determinants of Health. We know that the Social Determinants of Health require us to look upstream of health outcomes toward those wicked problems and social injustices in our society that lead to suffering, illness, disease, and death. In her book The Social Determinants of Health: Looking Upstream, Kathryn Strother Ratcliff writes that,

A growing consensus in many academic fields, in the World Health Organization (WHO), and among human rights spokespeople is that we need to take the social determinants of health more seriously. We have long focused on the biological causes of poor health (genes, germs, viruses) and on the contribution of the healthcare system to better health. But the focus is now changing. Examining social determinants is often referred to as an “upstream” approach, so named from the oft-used image of people drowning in a river. This image is typically credited to John McKinlay, author of a classic article in which he quotes his friend Irving Zola:

There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in. (McKinlay 1979: 9)[4]

Strother Ratcliff emphasizes that both roles are important – pulling people out of the stream (like our physicians do every day), and looking upstream for deeper problems (like we are trying to do here) – and she emphasizes that the upstream perspective must take racialization, gender and sexuality, and social and economic class into account. I agree for many reasons, and I see deep connections between Social Accountability, Social Justice, and EDI, that ought to be developed further.

But in this presentation, I want to look even further upstream from the Social Determinants of Health to the conceptual and ideological determinants behind the idea of Social Accountability. I will do so by drawing directly from the theme of this series: the Human Sciences. This term refers to a broad and interdisciplinary approach to human questions about knowledge in ways that cross the boundaries between the arts and the sciences. My goal is in some respects, very simple: I want to show how the idea of Social Accountability is based on a number of unexamined presuppositions that – if we examine them carefully – will help us in our efforts to move toward health equity and social justice.

So I will begin by providing a brief history of the discourse on Social Accountability. Then I will provide a series of conceptual distinctions in seven points that I think are essential for understanding the term and its responsible use, and then I will conclude with some instructive and concrete examples of how Social Accountability mediates between theory and practice.

2. HISTORY

The history of Social Accountability has been told and retold a number of times, so here I will only point to a lineage of key documents that have proceeded from 1995 to the present. Most of us will know the classic and traditional definition of Social Accountability, as:

“the obligation [of medical schools] to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve.”[5]

Most discourses return to foundational definitions like this one when they need to anchor in a shared vision or set of priorities, and Social Accountability is no different. Here I will point out that in the foundational WHO document called “Defining and Measuring the Social Accountability of Medical Schools” by Charles Boelen and Jeffrey Heck, “Accountability exists independently of whether a school acknowledges it and addresses it; all medical schools are accountable (i.e. liable to be called to account).”[6] But how?

Fast forward to the early 2000s when Health Canada published their report that takes up the WHO call in the context of Canadian medical schools. Alongside its framing of Social Accountability as a professional competency and guide for research and local partnerships, the Health Canada report suggested that the “Involvement of the community in identifying community needs, setting priorities, establishing and evaluating new models of practice is seen as critical.”[7]

A few years later, in 2006 Bob Woollard published an article in Medical Education where he suggested that Social Accountability is becoming a central concern for medical schools, and argues that “good intentions are not enough” and that we ought to distinguish between “between the social accountability of the institutions themselves and the social accountability of the graduates they produce.”[8]

A few years after that, in 2008 came the establishment of the AFMC Social Accountability Network,[9]  and 2009 saw a turn toward accreditation as a new area of growth for the conversation.[10] In 2010 – 100 years after the Flexner Report – the conversation on Social Accountability expanded through a three-round eight-month Delphi-driven process that resulted in the “Global Consensus for the Social Accountability of Medical Schools.” This report emphasized responsiveness to “current and future health needs and challenges in society,” strengthening “governance and partnerships with other stakeholders” and using “evaluation and accreditation to assess performance and impact.”[11]

And those who were advancing the Social Accountability movement around the world have been undertaking many of those tasks, including: the development of the CARE model of social accountability (which stands for Clinical activity, Advocacy, Research, and Education and training) that followed up on the 2001 Vision for Canadian Medical Schools document,[12] and the landmark article “Social accountability: The extra leap to excellence for educational institutions” by Boelen and Woollard that spoke to “the challenge of providing evidence that what we do responds to priority health needs.”[13] – and here I am thinking of the signal importance of the NOSM U Physician Tracking Study, which is one of the only data-driven means by which my institution could call itself socially accountable.

From there, several tools were developed like THEnet’s Social Accountability Framework in 2012,[14] the AMEE guide to producing a socially accountable medical school in 2016,[15] and the Institutional Self-Assessment Tool (ISAT) by The Network: Towards Unity for Health – a document that I have been helping to revise into a 2.0 version that reflects changes in this conversation.

By 2017, the Committee on Accreditation of Canadian Medical Schools (CACMS) had adopted Social Accountability as point 1.1.1 of its standards and elements,[16] and in 2020 the International Social Accountability and Accreditation Think Tank was formed – an AFMC committee that is now called the International Social Accountability and Accreditation Steering Committee (ISAASC). It’s been a privilege for me to be involved in ISAASC over the past year, and I can assure you that its work continues in very exciting new ways.

To cap off this brief history of documents I would like to point toward one final document that I think represents both a consolidation and extension of the discourse on Social Accountability, and that is Brett Schrewe’s 2023 dissertation, titled “Medical citizenship and the social right to health care in Canada: a genealogy of medical education discourses.”[17] Its fifth and sixth chapters provide perhaps the most focused and extensive history of Social Accountability, and certainly the most careful close reading of its key documents.[18] I will quote briefly from Schrewe’s argument in the dissertation where he calls for more clearly defined education for medical professional’s engagement with society. He writes:

Yet for a profession whose signature educational framework states a commitment to social accountability and claims authority through a foundation in its responsiveness to societal health care needs—needs which change with time and demand a flexible educational system that can change in step with them—a lack of significant educational content, an apparent mechanism, or even a clear directive to educate for recurrent and deep physician and professional engagement with society and its constitutive publics may thwart that commitment.[19]

This call from a physician who has a doctorate in education and who is schooled in the close reading techniques of the Humanities, means a great deal for the future of Social Accountability, and my aim in this presentation is to pick up and extend this call for a clearer understanding of the relationship between medicine and society. This brings me to the core of my presentation: a proposal for a philosophically and critically enriched approach to Social Accountability.

3. CONCEPT

As mentioned above, Social Accountability is a principle taught in medical schools that urges health professionals to respond to the needs of society. That much is clear. As I’ve just described, the definition of Social Accountability and the conversation on its application have grown considerably since the mid-1990s, and it has gained momentum as an institutional health policy strategy and an emerging part of accreditation standards.[20]

Today, Social Accountability is a term that names both individual professional conduct and broader health system transformation, and many places in between. For physicians in particular, the imperative to become more socially accountable in practice means improving doctor-patient relationships, strengthening physician-community connections, and bolstering the interaction between the medical profession and society. Physicians become more socially accountable by conducting themselves in socially just and compassionate[21] ways when responding to all patients (at the micro level), advocating for specific local community health needs (at the meso level), and engaging in humanitarian advocacy for the sake of general social welfare (at the macro level).[22]

But what exactly is Social Accountability and how does its most basic definition influence what physicians, researchers, and other professionals do and how they understand their obligations to the societies they are tasked to serve? To answer this question, I think we need to turn toward the enriching resources of critical social theory. Indeed, according to our own Erin Cameron and Brian Ross in their article “Socially Accountable Medical Education: Our Story Might Not Be Yours,” Social Accountability is a paradigm shift in medical education that calls for more complex and nuanced attention to social theory.[23]

And in fact, the connection between social theory and medicine continues to appear in the conversation on professionalism in medicine. In his December 6, 2023 address, “Transforming Postgraduate Medical Education: A Vision for Socially Just Specialty Training in Canada,” Dr. Saleem Razack – 2023 Professor-in-Residence at the Royal College of Physicians and Surgeons of Canada – called for physicians to engage in the work of social justice by mediating between the closed questions of a patient’s formal medical history, and the open and subjective character of their story. Razack foregrounded the need for physicians to develop the structural competencies that will allow them to engage with patients by using different knowledge systems (such as Two Eyed Seeing), while looking beyond the scientific paradigm and toward the Social Sciences and Humanities.

As a scholar of religion and culture who studies the critical and theoretical foundations of Social Accountability, I would like to push Razack’s call further by drawing on critical terms from my own discipline in service of a richer definition and practice of Social Accountability. Social Accountability and other related principles that guide many physicians – like Social Justice, EDI, and Health Equity – are not incidental to the practice of medicine. Nor are they fundamentally separate or in competition with traditional medical expertise.[24] Instead, Social Accountability is a concept that both reflects and informs the values that physicians and other health professionals hold. This means that how it is understood will inevitably influence how physicians treat their patients and their professional obligations to society. This is why I am seeking a simultaneously broader and more focused definition of Social Accountability.

The term “Social Accountability” is already a bit broader than it appears. Although the WHO definition is widely used, it is rarely compared with the use of the very same term by those who work in governance, transparency and anti-corruption – for example, by the World Bank.[25] Although the term is used in different ways in state governance and health professional education, one key similarity is how it critically seeks to reform relationships between individuals, communities, and institutions.

In short, Social Accountability is a name for a set of relations between individuals, communities, societies, and states, that is fundamentally political. Accountability is anything but a neutral term. Instead, it is a political concept that does not merely describe how people interact, but asserts how they should interact. In a recent study of the concept, Gianfranco Pasquino and Riccardo Pelizzo claim that: “Accountability is a democratic virtue.”[26] They then assert that accountability “is a process, not a link, because… it deploys itself at different points/stages in time, and in a way, it never ends.”

This alone should give us pause, and remind us that the moment we think that we have achieved Social Accountability – the moment we check it off the list – we have allowed our efforts toward it to become self-defeating. This ever-present risk of reducing Social Accountability to an end-product rather than a complex process is one major reason why I am proposing the following extended and philosophically-enriched definition:

Social Accountability is a value and virtue that reflects a critical theory of society founded on social bonds of public trust. Put differently, Social Accountability is a normative (not descriptive), critical (not neutral), and democratic (not enforceable) virtue that both relies upon and reinforces specific social bonds of public trust, all in ways that mediate between individuals, communities, and institutions.

Allow me to explain each aspect of this working definition because each specialized term in the preceding sentence can directly inform our work.

Social Accountability is a value because it reflects a normative decision to choose and invest in one way of thinking and acting over another. This means that when we act like Social Accountability is a given or imagine that everyone will agree on it or think the same way about it, we have forgotten its most basic characteristic: it is something that we must choose over other competing and conflicting values, such as the temptation to act unaccountably and without transparency or oversight. I make this assertion because I agree with and follow the work of Rahel Jaeggi,[27] a critical theorist who argues, in short, that although we may want to believe that we all get along in our pluralistic societies, the idea that we can abstain from involvement in conflicts of values is a fantasy. We may say “who am I to judge” or imagine that we have common values or even common sense, but the reality is that our societies are defined by conflicts of values, and it is better to admit this and find a way through together, than assume we all agree about what is important in this world. 

Point 1. Social Accountability is a value that we need to insist upon and argue for across professional and institutional contexts. It will not be adopted passively or naturally.

As a value among values, Social Accountability also cannot be reduced to contractual or economic agreements – these are not strong enough to account for its task of calling professionals to account for how they serve or do not serve society. If the values of Social Accountability are reduced to a social contract that one symbolically signs, or a financial relationship of payment or indebtedness between citizens and governments, then it is liable to become just another check-box on a list, rather than something that is pursued because of its inherent value. This is why I refer to Social Accountability as a virtue, for it seeks the public good in humanitarian and pro-social ways.

Point 2. Social Accountability is about more than a social contract or financial agreement. It is a value and virtue that must move within and then beyond contractual bonds toward humanitarian and social justification.

In addition to being a value and a virtue that is beyond contractual capture, Social Accountability is critical. This is because it responds to and seeks to transform states of affairs that are not (yet) as they should be. If individuals and institutions related to each other in responsible, accountable, and connective ways, the concept of Social Accountability would not exist. But Social Accountability represents an implicit critical theory of society because it arises from and then seeks to remedy an absence or break in human and institutional relationships. In short, people only experience the need for accountability when the bonds of trust that form the expectation of accountability are broken.[28]

Point 3. Social Accountability is a non-neutral and critical value that points to the fact that things in society are not yet how they should be. As such, Social Accountability refers to how we respond to ruptures, breaks, and injustices in our social bonds.

It follows then, that physicians who adopt Social Accountability as one of their key values are already engaged in the everyday practice of social critique.[29] This is because Social Accountability insists that the quality of the relationship between the medical profession and the society it serves ought to be improved. In a way, this brings Social Accountability into alignment with the aims of Quality Improvement (QI), but it does so in a way that should cause us to question what values are informing our vision of quality. The standards and measures that we use to define quality and its improvement are not universal across space and time, and across the globe. This means that our commitments to quality improvement and excellence cannot help but reflect the public values of our current cultural moment.

This brings me to the second part of the definition I proposed above. Social Accountability is founded on social bonds of public trust. This part of the definition may seem abstract and distant from the everyday lives of patients and physicians, but quite the opposite is true. If physicians and medical educators are serious about the value and virtue of Social Accountability, then it is essential first to see that the concept is based on the formation and breakage of bonds of trust, and then to set about strengthening those bonds of trust in contextually sensitive ways. 

Underneath the act of holding others to account and the experience of being held to account are the basic social bonds that connect human beings in pluralistic and diverse societies. We are here today because we share interests in medical education and we share social bonds that obligate and oblige us to attend an event and listen to a speaker.

If up until now, I have provided a critical theory of Social Accountability by revealing its normative foundations, then here I’ll turn briefly to Political Theology to say that the basic social bonds that animate Social Accountability are both religious and secular. The consensus by scholars of religion today is that the religious-secular distinction is a modern invention.[30] This means that for most of human history, social bonds have kept people connected in communities knit around what we now call religion. Consider with me that the etymological roots of the term “religion” in the Latin term “religio” refer to social bonds.

For example, in Ancient Rome, the term religio referred to “a homeostatic system of reciprocities moving back and forth across a boundary or bond—an emotional economy closely related to and reflecting the self-regulating ‘government of shame’ of cultures without powerful centralized institutions and means to enforce their claims to authority and legitimacy.”[31] Rather than thinking about religion purely in terms of knowledge and belief, recent social scientific approaches to the topic consider how the term names forms of life that reflect a kind of bond or being-bound, or a sense of “doubt, hesitation, constraint, scrupulousness, carefulness, anxiety, awe, fear, and dread” that makes one pause or decide on a different course of action.[32] Indeed, my first book, Postsecular History, focuses on how these social bonds are both secular and religious, especially when they entangle to form our sense of time.

The relationship between individuals and their communities and societies is structured by social bonds that obligate us to one another, based on some level of trust in others. These connections that bind people together are like a ligature or adhesive.[33] For example, individuals swear oaths in courts, governments, and medical schools, as a way of assuring the veracity of their speech and building up the bonds that oblige them to tell the truth, work in the public interest, and do no harm. But these oaths reflect the fact that we still seek extra assurance beyond everyday speech, and we still look for authoritative ways of trusting others. Our secular modern social bonds still owe a lot to the religiosities of previous centuries, and our swearing of oaths is one example of how we reoccupy religious structures in secular institutions.

Although this may seem obvious, it is helpful to consider that we would not expect to be accountable to another person or institution, or expect another person or institution to be accountable to us, if we did not share meaningful bonds. Indeed, the desire for more accountability in the doctor-patient relationship reflects the level of trust that the public has in the medical profession.

Point 4. Social Accountability is only something we expect because we have formed social bonds between individuals, communities, and societies. If we are not attending carefully to the specific social bonds that inform our expectations of accountability in our context, then we are missing the fundamental underpinnings of the concept.

So socially accountable practices ought to contribute to the resiliency, sustainability, and quality of the social bonds that cause us to expect accountability in the first place. In practice, this means that physicians and other health care professionals ought to see careful trust building as a cornerstone of their work. Without trust in the doctor-patient relationship, there can be no relationship of compassionate care. Without trust in the relationship between doctors and communities, community health needs will not be identified and will go unmet. Without trust in the institution of medicine – and there are many critiques of the medical establishment that illustrate such blind spots – there can be no socially accountable professionals or institutions.

Point 5. Social Accountability is defined by its response to breaks in public trust. The social bonds that cause us to expect that individuals would be accountable to each other or that institutions would be accountable to society are based on public trust. This means that the work of becoming more socially accountable must focus both on the reasons why public trust is broken, and strategies for its remediation.

How we think about Social Accountability is deeply related to the bonds of trust that hold together medicine and society. If this relationship is only presented in contractual, legal, or economic terms divorced from values and virtues, then its social and relational character risks being eclipsed. In practice, this limited way of thinking diminishes the human character of medicine by placing rationality, clinical proficiency, and evidence-based practice in competition with compassion, care, and relationality, when it is the careful combination of these virtues that promises to humanize medicine.

Social Accountability is not merely a social contract between physicians and society that binds them to their task of service in negative ways that are defined by the breaking of those contractual bonds. Rather, it is a positive value and virtue that promotes proactive responsiveness to society’s health needs.[34] A physician who considers their accountability to society as a mere contract may protectively remain within the letter of that contract so as not to break its bonds, but a physician who understands Social Accountability as an active and ongoing processthat contributes to the public good will constructively seek to better their interactions with patients and improve their service to their community. Indeed, for many physicians Social Accountability already extends beyond institutional bounds of professionalism and competency, and into the sphere of social, cultural, and public values – often being referred to as a global movement.[35]

Social accountability in health professional education plays many roles. It can serve to emphasize core values and be meaningfully integrated into institutional policy to support equity, diversity, and inclusivity as well as health equity. But it can also be reduced to a buzzword and emptied of meaning and applicability for institutions that struggle to be accountable. Stéphane Dufoix helpfully describes the tension between treating key terms (like Social Accountability) as “catchalls” that can mean anything, and “private clubs” that have restricted and policed meanings, and he opts to “not choose between these two options” but instead to treat such terms in their historical, critical, political, and ever-transforming contexts. He writes “Like all words, it [for him diaspora, for us Social Accountability] serves to denote only part of reality, one that isn’t always the same each time it is used.”[36]

Social Accountability is only two words, but together they form a concept and a category that is open to many uses and abuses. This means that it is essential to use the term in self-critical ways, lest it be emptied of its content or robbed of its integrity.

Point 6. The term “Social Accountability” cannot and should not be anxiously possessed by presenting it as overly narrow (through gatekeeping) or by opening it so much that it loses definition. Instead, the term should be used in ways that are accountable to the existing and future discourse on the topic.

The critical, conceptual, and theoretical underpinnings of Social Accountability are hidden players in its varied usage, and they deserve further scrutiny. A key article argues:

we should reject the assumption of the undeniable goodness of social accountability and instead critique social accountability in medical education, focusing on its meta-narratives, its underlying ideologies and assumptions, and the ways in which power and identity are expressed and negotiated through the social accountability discourse.[37]

I agree with Ritz, Beatty, and Ellaway when they argue that Social Accountability is not always good. It is only two words, and these words can be used in helpful or harmful ways. That is why – as they say – it is so essential to critique the concept but also to treat it as a critical concept. In short, my point is that Social Accountability is a critical theory of society that calls for more accountability where there is not enough, but it must also become a critical theory of itself. The concept of Social Accountability, if it is to have integrity and not be hypocritical, must be used in Socially Accountable ways. We are accountable for both its meaningful uses and the ways that it is reduced to a buzzword. This means that there is an essential form of self-reflexivity that ought to be built into Social Accountability if it is to have integrity.

Point 7. Social Accountability must be understood and used as a socially accountable concept. Because it explicitly calls for accountability, the concept itself must be used in ever more self-reflexive and self-critical ways so that its various uses can be held to account.

At the same time, the concept of Social Accountability can only do so much for us. We cannot expect the term itself to do the work of holding others (i.e., institutions and individuals) to account, and we cannot expect it to do the work for us as we learn how to be held accountable. Better to understand SA as a co-concept with others like Social Justice and Health Equity, than to place it in competition with such terms under the assumption that terminological differences will necessarily lead to the displacement of one term by another.[38] Better to engage in the constant process of renewal and critique of both terminology and social practices, than to fix the concept of SA in place or expect it to do what individual actions and institutional policies must do.

So, to sum up the propositions I have made, I’ll first return to my proposed definition and critical framework, and then to the seven points I have emphasized:

Seven Propositions on Social Accountability

  • Point 1. A Value. Social Accountability is a value that we need to insist upon and argue for across professional and institutional contexts. It will not be adopted passively or naturally. This means that we must advocate for it.
  • Point 2. A Virtue. Social Accountability is about more than a social contract or financial agreement. It is a value and virtue that must move within and then beyond contractual bonds toward humanitarian and social justification. This means that we cannot simply reference it; we must care about it.
  • Point 3. A Critical Response. Social Accountability is a non-neutral and critical value that points to the fact that things in society are not yet how they should be. As such, Social Accountability refers to how we respond to ruptures, breaks, and injustices in our social bonds. This means we need to look for places where there are no accountability structures and build them.
  • Point 4. Grounded in Social Bonds. Social Accountability is only something we expect because we have formed social bonds between individuals, communities, and societies. If we are not attending carefully to the specific social bonds that inform our expectations of accountability in our context, then we are missing the fundamental underpinnings of the concept. This means we must understand and bolster the social bonds that inform our context’s calls for accountability.
  • Point 5. Grounded in Trust. Social Accountability is defined by its response to breaks in public trust. The social bonds that cause us to expect that individuals would be accountable to each other, or that institutions would be accountable to society, are based on public trust. This means that the work of becoming more socially accountable must focus both on the reasons why public trust is broken, and strategies for its remediation. This means we must build trust through deep listening and relationship building where people are not treated as means to ends.
  • Point 6. Open-Ended. The term “Social Accountability” cannot and should not be anxiously possessed by presenting it as overly narrow (through gatekeeping) or by opening it so much that it loses definition. Instead, the term should be used in ways that are accountable to the existing and future discourse on the topic. This means we must use the term in response to how others have used it.
  • Point 7. Self-Reflexive. Social Accountability must be understood and used as a socially accountable concept. Because it explicitly calls for accountability, the concept itself must be used in ever more self-reflexive and self-critical ways so that its various uses can be held to account. This means we must criticize reductive uses of the term that remove its critical edge.

4. THEORY-PRACTICE

But how do these conceptual distinctions help us in our work? I’ll close with some examples of how each point becomes very practical.

Social Accountability and Community

An essential aspect of Social Accountability – without which it is incapable of achieving its goals – is community engagement. Most of the documents I surveyed at the outset emphasize community engagement, but few Social Accountability initiatives achieve meaningful long-term community engagement in their work. I suspect that part of the difficulty comes from the undefined character that the word “community” takes on in the discourse on Social Accountability.

Because Social Accountability requires clear and specific connections with the communities that health professionals and researchers are tasked to serve, we must think clearly about who those communities are, how representatives of those communities represent those communities, and what the mandate and purview of the institution is in relation to those communities. If it is to have integrity, Social Accountability initiatives and their leaders must be specific and precise. This means moving beyond discussion of “community” in the abstract and singular, and toward the formation of meaningful and non-instrumental bonds of connection and trust with plural, specific, and concrete communities, populations, geographies, and representatives.

On community, our key questions should be:

  • What are the social bonds within our specific communities from which our expectations of accountability spring?
  • What are the specific characteristics of those social bonds? Are they built on social contracts, pro-social forms of trust, or merely financial exchanges?
  • How exactly are communities represented? How are representatives selected by their communities?

ISAT and the Social Accountability Fellowship

This problem of identifying, engaging with, and responding to the health needs and priorities of communities becomes even more complicated on a global scale. For the past year I have served as the Social Accountability Coordinator in a joint position between NOSM U and TUFH, and I have been working with Nick Torres and others on a Social Accountability Fellowship that draws from all the regions of the globe and provides a forum and resources for deans of medical schools to bring their institutions closer to Social Accountability. They do this by working with the Indicators for Social Accountability Tool (ISAT), which – although it is not an accreditation tool – is a way for medical schools to become more self-aware and self-critical about where exactly they stand in their journey’s toward becoming more socially accountable. Indeed, two of our Canadian fellows have expressed that the tool has helped them in their accreditation processes.

While gathering feedback for a new version of the ISAT from some of those who have used the tool and some who are currently using it, an overwhelming consensus was that Social Accountability requires advocacy, it needs champions who will use their political will and institutional power to promote it, it requires the reforming of specific values, and it must be an open-ended process that does not artificially conclude.

A major complexity, however, is that we do not live in a world of universally agreed upon values. Despite the best efforts of global organizations like the WHO or UN, it is unlikely that our global environment will converge on what matters most. This means we need to navigate differences as we do our work, and I think this is possible if we retain a universal vision without allowing that vision to universalize or totalize what we are talking about.

The final two points I suggest in my enriched definition attempt to protect against these problems of universality. No matter what, any universal vision will be confronted, and should be confronted with ways that it does not apply to specific contexts. What matters is that the universal vision of socially accountable and socially just health for all, is able to respond to difference in open-ended and self-reflexive ways.

A universal vision for socially accountable medical education needs to navigate between realism and aspiration, for example, because of the vast differences in government involvement in medical school admissions. Countries where medical schools control their admission standards and measures cannot be held to same standard as countries where governments control those conditions.

But one thing I have noticed in my interactions with our 2023 Social Accountability Fellows and with those involved in the ISAT revisions is that the conversation on Social Accountability has an unusual level of good will amongst its leaders. Even though there can be no one-size-fits-all model, there is a relatively ubiquitous level of mutual support amongst many who are involved in this conversation.

I have also experienced that here at the Arcand Centre, and amongst those who are involved with The CREATE Project – a SSHRC Partnership Grant which gives us the occasion to think about and advance not only Social Accountability in medical education, but also new models for Socially Accountable Research, in the context of  Socially Accountable Research Networks. Led by Erin Cameron, myself and my colleague Jessica Jurgutis and others are setting out to both facilitate and study a research network that is focused on Social Accountability in ways that mediate between its global character and local/regional emphasis.

Social Accountability as a Methodology

For us, Social Accountability is a methodology that informs both our research and our project governance. We’re currently asking questions like “What is socially accountable research?” and “how is it expressed and experienced?” One of our key questions in the project is: “How do language, positionality, and worldview influence Socially Accountable Research?” And several of my proposed extensions of Social Accountability address this.

But I will say something about Social Accountability and language. If the concept is to have any sort of integrity at all, it must be used flexibly, with the understanding that it is only a name – a signifier that points toward and is not the same as its signified content. We must remain open to the idea that there are many initiatives underway in many contexts that align and resonate with Social Accountability, but go by other names, and we should take care not to imperialistically claim the activities of others for the cause of Social Accountability. We must become accountable for our language, lest it become colonial and possessive by claiming things that are not its own or using coercive ideal types that present only the good versions of our concepts. I elaborate more on this approach to language in my recent book Ontologies of Violence.

[1] Buchman S, Woollard R, Meili R, Goel R. Practising social accountability: From theory to action. Can Fam Physician. 2016 Jan;62(1):15-8. PMID: 26796826; PMCID: PMC4721832.

[2] https://plato.stanford.edu/entries/critical-theory/

[3] https://politicaltheology.com/political-theology-network-points-of-unity/

[4] Kathryn Strother Ratcliff, The Social Determinants of Health: Looking Upstream (London: Polity, 2017), .

[5] Boelen C., and Heck JE, Defining and Measuring the Social Accountability of Medical Schools. Geneva: World Health Organization, 1995. https://apps.who.int/iris/handle/10665/59441  (p. 3).

[6] Ibid.

[7] The 2001 Health Canada report “Social Accountability: A Vision for Canadian Medical Schools” (https://www.afmc.ca/wp-content/uploads/2022/10/sa_vision_canadian_medical_schools_en.pdf)

[8] Caring for a common future: Medical schools’ social accountability, Woollard (2006) Medical Education

[9] (https://www.afmc.ca/resources-data/social-accountability/)

[10] The 2009 publication of Boelen C, Woollard B. Social accountability and accreditation: a new frontier for educational institutions. Med Educ. 2009 Sep;43(9):887-94. doi: 10.1111/j.1365-2923.2009.03413.x

[11] Global Consensus for the Social Accountability of Medical Schools (https://healthsocialaccountability.sites.olt.ubc.ca/files/2011/06/11-06-07-GCSA-English-pdf-style.pdf)

[12] Meili R, Ganem-Cuenca A, Leung JW, Zaleschuk D. The CARE model of social accountability: promoting cultural change. Acad Med. 2011 Sep;86(9):1114-9. doi: 10.1097/ACM.0b013e318226adf6. PMID: 21785308.

[13] Charles, Boelen & Woollard, Robert. (2011). Social accountability: The extra leap to excellence for educational institutions. Medical teacher. 33. 614-9. 10.3109/0142159X.2011.590248.

[14] https://thenetcommunity.org/the-framework/

[15] Producing a socially accountable medical school: AMEE guide no. 109, Boelen et al., (2016) Medical Teacher

[16] https://cacms-cafmc.ca/wp-content/uploads/2023/02/CACMS-Standards-and-Elements-AY-2024-2025.pdf

[17] Brett Schrewe’s dissertation “Medical citizenship and the social right to health care in Canada: a genealogy of medical education discourses.” Vancouver: University of British Columbia, August 2023. https://open.library.ubc.ca/soa/cIRcle/collections/ubctheses/24/items/1.0434651 pp. 256-340, 482.

[18] Part of Schrewe’s argument is that Social Accountability is used as a persuasive term within the discourse on medical professionalism, and that there are in fact two discourses at work: 1. An inward conversation on “working within the system for better individual clinical care” – which began in the early 2000s and which focused on individual advocacy, and then turned its attention to professional competency. 2. An outward conversation on “working to change the system for a healthier society” which began in the late 1960s, and which appears in many federal policy documents. (p. 232).

[19] Ibid, 233.

[20] Cameron E., Larche C., Kennel M., Woollard R., Boelen C., & Marsh D. (2023). Leveraging Accreditation to Move Health Institutions Toward Social Accountability. Social Innovations Journal, 21 (2023) Retrieved from https://socialinnovationsjournal.com/index.php/sij/article/view/6784

[21] Hoi F. Cheu, Pauline Sameshima, Roger Strasser, Amy R. Clithero-Eridon, Brian Ross, Erin Cameron, Robyn Preston, Jill Allison & Connie Hu (2023) Teaching compassion for social accountability: A parallaxic investigation, Medical Teacher, 45:4, 404-411, DOI: 10.1080/0142159X.2022.2136516

[22] College of Family Physicians of Canada. A new vision for Canada: Family Practice—The Patient’s Medical Home 2019 – Community Adaptiveness and Social Accountability. Mississauga, ON: College of Family Physicians of Canada; 2019. p. 18. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf See also: https://www.tandfonline.com/doi/full/10.1080/0142159X.2024.2306842

[23] Ross, B.M., & Cameron, E. Socially Accountable Medical Education: Our Story Might Not Be Yours. Higher Education Studies; Vol. 11, No. 1; 2021. https://doi.org/10.5539/hes.v11n1p114

[24] This claim stands in sharp contrast with recent op-eds in The National Post that assume a fundamental disjunction between antiracism and medical expertise. See Michael Higgins, “‘Anti-racist’ doctors would put social justice above medical expertise: New proposal would centre Canada’s framework for physician training around ‘anti-oppression’” National Post. Nov 27, 2023.

[25] See, for example, Opening the Black Box: The Contextual Drivers of Social Accountability. Ed. Grandvoinnet H, Aslam G, and Raha S. Washington, DC: World Bank, 2015.

[26] Gianfranco Pasquino and Riccardo Pelizzo, The Culture of Accountability A Democratic Virtue (Routledge, 2023). The authors of The Culture of Accountability A Democratic Virtue write further that accountability involves three separate but overlapping processes:

  • #1. “Taking into account” through a willingness to consider and make changes in light of constituents’ feedback.
  • #2. “Keeping into account” through ongoing actions taken to preserve congruence with the preferences of constituents.
  • #3. “Giving account” by explaining conduct to constituents.

[27] See Rahel Jaeggi, Critique of Forms of Life. Trans Ciaran Cronin (Cambridge, MA: Belknap Press, 2018).

[28] Axel Honneth writes in similar terms of recognition: “Subjects only experience disrespect in what they can grasp as violations of the normative claims they have come to know in their socialization as justified implications of established principles of recognition.” Honneth A, Disrespect: The Normative Foundations of Critical Theory. Polity, 2007 (p. xii).

[29] Contemporary critical theorists like Robin Celikates understand “critique” to be a social practice that all people are engaged in, with varying levels of self-consciousness and self-criticism. See Celikates R, Critique as Social Practice: Critical Theory and Social Self-Understanding. Rowman and Littlefield, 2018.

[30] Brent Nongbri, Before Religion: A History of a Modern Concept (New Haven: Yale University Press, 2013).

[31] Daniel Boyarin and Carolyn Barton, Imagine No Religion: How Modern Abstractions Hide Ancient Realities (New York: Fordham University Press, 2016), 16.

[32] Ibid, 17.

[33] Whether we understand accountability as a social and moral value or a mere fact of economic relations, the expectation of accountability is founded on trust, which underpins all social bonds. It is at the level of trust that proponents of SA ought to intervene, in constructive and critical ways. The word “trust” bears an historical and figural relationship with the Latin term credere, from which the English language also receives words for legitimacy like “credibility” and financial terms like “credit.”[33] To trust a person or institution requires forming and maintaining a bond that establishes and invests in agreed-upon boundaries. These boundaries are transgressed when people or institutions are not held to account for their actions, and terms like justice, responsibility, responsiveness, and accountability are each ways of forming, communicating, and maintaining social bonds and connections that can respond to society’s needs.

Most social bonds in pluralistic western democracies are both religious and secular. For example, legal testimony (in governance) and the swearing of the Hippocratic oath (in medical schools) both serve as ligatures that bond and oblige by appeal to bonds of trust that far exceed deflationary definitions of secularity. By appeal to transcendental values and virtues, social accountability is already a form of political theology. In the example of the oath, the act of holding a person or institution to account makes recourse to measurements and evaluations – an activity which is determined by value and values because we measure and evaluate in accordance to what we value. But the desire for measurement often ironically cuts against the social character of social accountability. Accountability can be situated in relation to the bonds of governance, policy, and law, but for these bonds to have persuasive power they are often anchored in immeasurables. This often creates a problematic search for key images to ground the concept when accountability fails. As such, this chapter argues – via key figures in Political theology – for a normative movement away from overdetermining social bonds with terms like biopolitics, sovereignty, and blood, to more promising paradigms of care, kinship, and mutual aid.

Bonds of trust can be formed in economically-driven ways by the threats (of foreclosure and destitution) that underpin many forms of financial debt, or they can be formed by properly social bonds of trust that are formed outside of coercive and violent means in communities of care, kinship, and mutual aid (and indeed many places in between the poles of this ideal-type distinction). This chapter begins by linking together the violence of financial capitalism in the neoliberal economization of the social with crises in public values wherein the process of valuation itself is blindered by myopic visions of greed and fear.

[34] Here I am challenging the notion that contractual language can capture and express the deep social bonds that bind together medicine and society. For a more complex view that is still beholden to the contractual paradigm, see: Cruess, Sylvia R. Professionalism and Medicine’s Social Contract with Society. Clinical Orthopaedics and Related Research 449: 170-176, August 2006. DOI: 10.1097/01.blo.0000229275.66570.97

[35] See Mohamed H. Taha, Mohamed E. Abdalla, Majed M. Saleh Wadi, Husameldin E. Khalafalla, Maryam Akbarilakeh, The implementation of social accountability in medical schools in Eastern Mediterranean region: A scoping review. Journal of Taibah University Medical Sciences. Volume 18, Issue 1. 2023. https://doi.org/10.1016/j.jtumed.2022.08.002.

[36] Stéphane Dufoix, Diasporas (Los Angeles: University of California Press, 2008), 2.

[37] Ritz S, Beatty K, and Ellaway R, Accounting for Social Accountability Developing Critiques of Social Accountability within Medical Education. Education for Health 27(2): 152-157, May-Aug 2014. DOI: 10.4103/1357-6283.143747

[38] See the argument in Maxwell Kennel, Ontologies of Violence: Deconstruction, Pacifism, and Displacement. Leiden: Brill, 2023.