Structural competency in global perspective

This special issue aims to help fill two critical gaps in the growing literature as well as in practice. First, to bring together scholars and practitioners from around the world who develop, practice, review, and question structural competency with the aim of promoting a dialogue with related approaches, such as Latin American Social Medicine, Collective Health, and others, which have been key in diverse geographical and social settings. Second, to contribute to expanding structural competency beyond clinical medicine to include other health-related areas such as social work, global health, public health practice, epidemiological research, health policy, community organisation and beyond. This conceptual expansion is currently taking place in structural competency, and we hope that this volume will help to raise awareness and reinforce what is already happening. In sum, this collection of articles puts structural competency more rigorously and actively in conversation with different geographic, political, social, and professional contexts worldwide. We hope this conversation sparks further development in scholarly, political and community movements for social and health justice.

The Right to Health Care Viewed from the Indigenous Research Paradigm: Violations of the Rights of an Aymara Warmi in Chile's Tarapacá Region

This paper reflects on the right to health care from the Indigenous research paradigm. We analyze the case of an Aymara wise warmi (woman) who died after the Chilean health care system failed to provide culturally appropriate care. In the wake of her death, our cooperative launched an interdisciplinary and collaborative research project in an effort to file an administrative complaint against the family health center that treated her. We explore the events surrounding her treatment and death, as well as the institutional written response. Our work elucidates the significant differences that exist between institutional and Indigenous perspectives on what constitutes a violation of the right to health care. We demonstrate that in order to establish the existence of such violations, Aymara people are compelled to develop evidence using a naturalistic scientific and legal framework that does not coincide with their ontology. Consequently, some events and violations are not legally recognized as culturally inappropriate health care unless they are viewed through an Indigenous lens. Finally, we reflect on the problem of evidence production, specifically regarding the right to health care. We argue that the fight for the right to health care can benefit from the Indigenous research paradigm-not only for the benefit of Indigenous people but also to provide culturally appropriate care to all people.

Structural competency, Latin American social medicine, and collective health: Exploring shared lessons through the work of Jaime Breilh

ABSTRACTStructural competency is a recent framework for understanding and addressing the structural drivers of disease. Latin American Social Medicine and Collective Health is a decades-long movement similarly concerned with the study and transformation of social structures to achieve health equity. In this paper, we put insights from Latin American Social Medicine and Collective Health into conversation with the developing structural competency framework. We focus specifically on insights from Jaime Breilh's new article summarising his theoretical work on medical ethics and rights in this special issue and his new book, Critical Epidemiology and the People's Health. This paper is comprised of three parts. Part 1 provides an introduction to the structural competency framework. Part 2 provides an overview of the Latin American Social Medicine and Collective Health movement, along with a summary of the social determination of health paradigm. Part 3 places insights from these works into conversation with structural competency and considers ways in which Latin American Social Medicine and Collective Health might inform the further development of structural competency, and potentially vice versa. The paper closes by calling for greater attention to Latin American Social Medicine and Collective Health among those committed to health equity within the anglophone world.

Beyond the classroom: The development of collective structural competency in pro-migrant activism

Structural competency proposals have been developed as part of an effort to infuse clinical training with a structural focus. Framed in the context of medical education, the discussion on structural competency naturally emphasises the development of such competency in healthcare workers. In this article, we shift the focus to reflect on how the work of migrant community leaders may involve the development of structural competencies and what can be learned from this complementary perspective. We analysed the development of structural competency in an immigrant rights organisation in northern Chile. We conducted focus groups with migrant leaders and volunteers and used the tools proposed by the Structural Competency Working Group to facilitate dialogue. This allowed us to verify the development of structural competency and other collective competencies, including the capacity to create a protected space for circulating experiences and knowledge; coordinate a heterogeneous group of agents; have a socio-legal impact; and maintain autonomy concerning ideological production. This article introduces the concept of collective structural competency and reflects on the importance of expanding beyond the common medical-centred approach when considering structural competency.

Ideological assumptions of Chile's international migrant healthcare policy: A critical discourse analysis

In the current historical moment of rewriting the Chilean Constitution, there are new hopes for producing a different socio-legal, political-economic and public health order. The Chilean case holds important implications for global health practitioners, researchers and policy-makers because it clearly shows both the impacts of neoliberal processes on a worldwide scale and neoliberal policy responses. This article contributes to the field of global health policy critical analysis by offering scrutiny of Chile's international migrant healthcare policy from the perspective of its ideological assumptions. We apply Fairclough's analytical perspective to the Chilean migrant healthcare policy, identifying its components, argumentative premises and ideological assumptions that contribute to the reproduction of the processes of social determination. It allows us to identify bias mobilisation, exclusion, and subordinate inclusion processes that systematically lead to the omission of structural processes in the social determination of migrants' healthcare, contributing to their reproduction. We conclude by problematising the place of academia in said reproduction to the extent that the concepts and premises they use remain in the ideological territory of exclusion of the structural defined by the policy, disconnecting reflection and action in the health field from collective demands.

Thinking with and Against the Social Determinants of Health: The Latin American Social Medicine (Collective Health) Critique from Jaime Breilh

The concept of the social determinants of health has become increasingly accepted and mainstream in anglophone public health over the past three decades. Moreover, it has been widely adopted into diverse geographic, sociocultural, and linguistic contexts. By recognizing the role of social conditions in influencing health inequalities, the concept challenges narrow behavioral and reductive biological understandings of health. Despite this, scholars and activists have critiqued the concept of the social determinants of health for being incomplete and even misrepresenting the true nature of health inequities. Arguably, these critiques have been most thoroughly developed among those working in the Latin American social medicine and collective health traditions who formulated the "social determination of health" paradigm and the concept of interculturality decades prior to the advent of the social determinants of health. We draw on Jaime Breilh's main works, with a focus on the recently published book, Critical Epidemiology and the People's Health, to (1) provide a broad overview of the social determination of health paradigm and its approach to interculturality and (2) clarify how these ideas and the broader collective health movement challenge assumptions within the social determinants of health concept.

Indigenous Border Migrants and (Im)Mobility Policies in Chile in Times of COVID-19

The commodification of healthcare and the structural violence towards the migrant population in the Chilean system materialize in a series of structural barriers to accessing healthcare. In the face of this structural vulnerability, cross-border health mobility is one of the primary resources of indigenous border migrants living in the Tarapacá region (Chile). This involves crossing the border of both people (specialists/patients) and objects (such as ritual supplies or biomedicines), which play a crucial role as, in many cases, it is the only way to satisfy their healthcare needs. The security-orientated geopolitics of border closure (Plan Frontera Segura) has been reinforced by immobility policies linked to the COVID-19 pandemic. While doing so leaves people without the fundamental resource of healthcare mobility or obliges them to cross the border via unauthorized crossings, exposing them to criminalization and abuse by different agents of violence (the military, people smugglers, etc.). In this paper, we will offer a description of these processes of (im)mobility, analyzing their conformation both by the current policies of the Chilean State and by the notorious deficiency in indigenous and migrant rights, denouncing the material impact they have on the health/illness/care process of indigenous migrants.

How Should Clinicians Express Solidarity With Asylum Seekers at the US-Mexico Border?

Migrants along the US-Mexico border have been subjected to transnational violence created by international policy, militaristic intervention, and multinational organizational administration of border operations. The COVID-19 pandemic compounded migrants' vulnerabilities and provoked several logistical and ethical problems for US-based clinicians and organizations. This commentary examines how the concept of transnational solidarity facilitates analysis of clinicians' and migrants' shared historical and structural vulnerabilities. This commentary also suggests how actions implemented by one organization in Tijuana, Mexico, could be scaled more broadly for care of migrants and asylum seekers in other transnational health care settings.

Structural vulnerability: migration and health in social context

Based on the authors’ work in Latin America and Africa, this article describes and applies the concept ‘structural vulnerability’ to the challenges of clinical care and healthcare advocacy for migrants. This concept helps consider how specific social, economic and political hierarchies and policies produce and pattern poor health in two case studies: one at the USA–Mexico border and another in Djibouti. Migrants’ and providers’ various entanglements within inequitable and sometimes violent global migration systems can produce shared structural vulnerabilities that then differentially affect health and other outcomes. In response, we argue providers require specialised training and support; professional associations, healthcare institutions, universities and humanitarian organisations should work to end the criminalisation of medical and humanitarian assistance to migrants; migrants should help lead efforts to reform medical and humanitarian interventions; and alternative care models in Global South to address the structural vulnerabilities inherent to migration and asylum should be supported.

Perspectivas teóricas sobre salud y migración: determinantes sociales, transnacionalismo y vulnerabilidad estructural

Resumen El artículo analiza críticamente las tres aproximaciones teóricas contemporáneas más importantes en el abordaje del binomio salud-migración: el enfoque de determinantes sociales de la Organización Mundial de la Salud; los estudios sobre transnacionalismo y salud; y las propuestas sobre vulnerabilidad estructural. Se exponen las ideas centrales que les caracterizan y se presentan las principales críticas realizadas. Dado que la mayor parte de la literatura actual está siendo publicada en inglés, el artículo acerca de manera sintética algunas de las principales contribuciones en la materia al público hispanohablante, siendo el primer trabajo de este tipo que incluye la aproximación de la vulnerabilidad estructural. El análisis se apoyó en el software CAQDAS Nvivo, utilizando análisis de contenido sumariante, estructurante y explicativo. El trabajo enfatiza la importancia de los procesos de determinación estructural de la salud de los migrantes, y concluye abogando por un análisis de las convenciones científicas presentes en las perspectivas teóricas, en tanto estas tienen un impacto concreto en la salud de los migrantes, como fundamentos de políticas y como materia prima para el sentido común.