Volume 103, February 2014, Pages 126–133
Structural Stigma and Population Health
Structural competency: Theorizing a new medical engagement with stigma and inequality
- Jonathan M. Metzla, , ,
,
- Helena Hansenb, c
- Under a Creative Commons license
Open Access
Highlights
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- Proposes changes to U.S. medical education that will infuse clinical training with structural awareness.
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- Moves beyond “cultural competency” to address how structures produce health inequalities.
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- “Structural competency” consists of training in five core competencies.
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- Provides examples of structural health scholarship and structural interventions.
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- Ultimately argues for medical models of structural change.
Abstract
This
paper describes a shift in medical education away from pedagogic
approaches to stigma and inequalities that emphasize cross-cultural
understandings of individual patients, toward attention to forces that
influence health outcomes at levels above individual interactions. It
reviews existing structural approaches to stigma and health inequalities
developed outside of medicine, and proposes changes to U.S. medical
education that will infuse clinical training with a structural focus.
The approach, termed “structural competency,” consists of training in
five core competencies: 1) recognizing the structures that shape
clinical interactions; 2) developing an extra-clinical language of
structure; 3) rearticulating “cultural” formulations in structural
terms; 4) observing and imagining structural interventions; and 5)
developing structural humility. Examples are provided of structural
health scholarship that should be adopted into medical didactic
curricula, and of structural interventions that can provide
participant-observation opportunities for clinical trainees. The paper
ultimately argues that increasing recognition of the ways in which
social and economic forces produce symptoms or methylate genes then
needs to be better coupled with medical models for structural change.
Keywords
- Stigma;
- Cultural competency;
- Medical education;
- Social determinates of health
Introduction
A
patient walks into a doctor's office speaking a language that the
doctor struggles to understand. The patient points to his chest while
making pain gestures. Or mimics actions that suggest a seizure. Or
fights to breathe. But the doctor is in her first week of residency,
having just moved from rural Indiana to the Bronx, New York. And the
patient grew up in low income housing and is on methadone maintenance.
Or lives in a Hmong neighborhood where English is the third tongue. Or
is an HIV-positive gay man who spends his life surrounded by a
tight-knit community of orthodox Jews.
For
much of the past two decades, “cultural competency” has been the rubric
most often deployed in U.S. medical education for addressing the
tensions of such moments of clinical encounter. Competency, in this
formulation, implies the trained ability to identify cross-cultural
expressions of illness and health, and to thus counteract the
marginalization of patients by race, ethnicity, social class, religion,
sexual orientation, or other markers of difference. Clinical
professionals learn approaches to communication, diagnosis and treatment
that take into account culturally specific sources of stigma, such as
the stigma of mental health diagnoses among Asian immigrants, or the
stigma of HIV and homosexuality in certain religious communities.
Doctors train by analyzing vignettes that depict instances where
“cultural” variables impact symptom presentations or attitudes about
care. “Mrs. Jones is an African American woman in her mid-60s who
comes late to her office visit and refuses to take her blood pressure
medication as prescribed.” Or, “You see a Mexican migrant who just received health counseling for Type II diabetes eating fried tortillas in the waiting room.”
Meanwhile, nurses develop “linguistic competencies” that teach them
culturally sensitive, non-judgmental ways to build rapport with such
patients. And pharmacists train in “communication skills” aimed to help
build relationships when working in “multicultural settings” ( American Association of Colleges of Pharmacy, 2006 and Perez, 2008).
These
are not insignificant developments. Cultural competency emerged during
an era when U.S. medicine failed to acknowledge the importance of
diversity issues (National Juneteenth Medical Commission).
In the twenty years hence, it helped promote consideration of the
impact of stigma and bias into treatment decisions. Yet the politics of
the present moment challenge cultural competency's basic premise: that
having a culturally sensitive clinician reduces patients' overall
experience of stigma or improves health outcomes. Increasingly, we hear
that low-income African Americans are unable to comply with doctors'
orders to take their medications with food, not because they harbor
cultural mistrust of the medical establishment, but because they live in
food deserts with no access to grocery stores. Or, that Central
American immigrants who are at risk for Type-II Diabetes refuse to
exercise, not because they are uneducated about the benefits of weight
reduction, but because their neighborhoods have no gyms or sidewalks or
parks. Or, that small numbers of opulent white Americans pay for their
healthcare out of pocket, not because they do not qualify for coverage,
but because the tax breaks and advantages they receive allow them to pay
cash for office visits with elite practitioners who do not accept
insurance. Or even that doctors overlook “cultural” variables, not
because they are insensitive, but because they work in clinics with
inadequate resources, and dwindling community support. These and other
encounters suggest how the clinical presentations of persons at both
ends of the economic spectrum are shaped by “cultural” variables, and
also by the economic and political conditions that produce and racialize
inequalities in health in the first place. And, that stigma and
cultural conflict in health-care settings needs be understood as the
sequellae of a host of financial, legal, governmental, and ultimately
ethical decisions with which medicine must engage politically if it
wishes to help its patients clinically.
This
paper tracks an evolving discourse that redefines cultural competency
in structural terms. We theorize a five-step conceptual model meant to
promote awareness of forces that influence health outcomes at levels
above individual interactions. We argue that, if stigmas are not
primarily produced in individual encounters but are enacted there due to
structural causes, it then follows that clinical training must shift
its gaze from an exclusive focus on the individual encounter to include
the organization of institutions and policies, as well as of
neighborhoods and cities, if clinicians are to impact stigma-related
health inequalities.
As this
special issue attests, public health, social science, and critical race
studies scholars have, over the last decade, begun to locate stigma, not
just in the attitudes of individual persons, but in the actions of
institutions, markets, and health care delivery systems (Bonilla-Silva, 2003; Hatzenbuehler & Link, 2014).
This literature importantly reveals how stigma in clinical encounters
needs be addressed in the institutions and social conditions that
produce the markers of exclusion that we call stigma, as well as in
on-the-ground encounters. Similar sensibilities now suffuse a number of
interventions that address the material realities of illness and health.
These interventions have, to this point, been disparate and
disciplinary, and thus largely developed outside of clinical practice.
For instance, global-health students at Harvard learn to think about
“sickness,” diagnosis, and treatment in relation to food and medication
distribution networks (Farmer, Nizeye, Stulac, & Keshavjee, 2006).
Masters students at the Michigan College of Architecture and Urban
Design form the first cohort of a new program in Design/Health, train to
build city environments that promote health (Taubman College). And sociologists learn to observe the interplay of social structures and “neighborhood effects” (Sampson, 2012).
These and other initiatives suggest possibilities for a major shift in
the objects of clinical intervention assumed by cultural competency
training, and in the broader outcomes sought by considering the impact
of “culture” on clinical interactions.
We
cull generalizable principles from a number of medical
and extra-medical literatures to propose a new paradigm for
medical education, structural competency ( Metzl, 2010 and structuralcompetency).
Central to our intervention is the belief that, just as stigma in
clinical encounters must be addressed structurally, so too must
inequalities in health be conceptualized in relation to the institutions
and social conditions that determine health related resources. We
contend that medical education needs to more systematically train
health-care professionals to think about how such variables as race,
class, gender, and ethnicity are shaped both by the interactions of two
persons in a room, and by the larger structural contexts in which their
interactions take place. And, that as such, clinicians require skills
that help them treat persons that come to clinics as patients, and at
the same time recognize how social and economic determinants, biases,
inequities, and blind spots shape health and illness long before doctors
or patients enter examination rooms.
In
1968, the civil-rights activist Stokely Carmichael famously assailed
forms of racial bias embedded, not in actions or beliefs of individuals,
but in the functions of social structures and institutions. “I don't
deal with the individual,” he said. “I think it's a cop out when people
talk about the individual.” Instead, speaking to a group of
mental-health practitioners, Carmichael protested the silent racism of
“established and respected forces in the society” that functioned above
the level of individual perceptions or intentions, and that worked to
maintain the status quo through such structures as zoning laws,
economics, schools, and courts. Institutionalized racism, he argued, “is
less overt, far more subtle, less identifiable in terms of specific
individuals committing the acts, but is no less destructive of human
life” (Carmichael, 2003: 151).
Attention
to structure as an organizing principle in medical education seems
particularly important at the present moment because the forces
Carmichael described have become ever-more destructive to human life.
Evidence also suggests that inattention to these forces has caused a
crisis of confidence for which American medical education is
ill-prepared.
On
the one hand, US physicians have never known more about the ways in
which the pathologies of social systems impact the material realities of
their patient's lives. Epigenetics research demonstrates, at the level
of gene methylation, how high-stress, resource-poor environments can
produce risk factors for disease that last for generations (Johnstone & Baylin, 2010).
Meanwhile, nueuroscientists show neuronal linkages between social
exclusion, poverty, hampered brain development, and mental disorders (Buwaldaa et al., 2005 and Evans and Schamberg, 2009).
And economists prove that low income persons can reduce their rates of
obesity, diabetes, and major depression by moving to safer, more
affluent neighborhoods (Judwig, 2011).
These are but a few examples of the types of research that doctors can
now access—at a level of microscopic and macroscopic precision
unimaginable in Carmichael's time—to understand how diseased or
impoverished economic infrastructures can lead to diseased or
impoverished, or imbalanced bodies or minds. And, how locating
race-based symptoms on the bodies of marginalized or mainstream persons
risks turning a blind eye to the racialized, stratified economies in
which marginalized and mainstreamed bodies live, work, and attempt to
survive.
On the other hand,
many of these physicians work in a country that has never invested less
in infrastructure, or done less to correct fatal and fatalizing
inequities—even in the aftermath of the Affordable Care Act. Bridges,
roads, clinics, and public transportation and food distribution programs
decay in many US urban settings, along with the social programs that
sustained them (Davey, 2011). Some locales prosper, while many others face a state that urban planners define as “infrastructure failure.” As U.S.
Housing and Urban Development Secretary Shaun Donovan recently put it,
“you can predict the life expectancy of a child by the zip code in which
they grow up” (Bostic & Lavizzo-Mourey, 2011).
This
divergence, between knowing a lot about the health effects of wealth
imbalances and doing little to address them, puts US medicine in a
particular bind. Its practitioners ostensibly want to help the persons
who come before them in times of need. Yet when “social” issues are at
play, these practitioners often know not what to do about it. Fully 85%
of primary care providers and pediatricians polled in a recent Robert
Wood Johnson survey agreed with the statement that “unmet social needs
are leading directly to worse health for all Americans” while at the
same time voicing concern that they did not “feel confident in their
capacity to meet their patients' social needs,” and that their failure
to do so “impedes their ability to provide care” (Harris Interactive, 2011).
Meanwhile, increasing numbers of physicians cite structural factors,
such as restrictive insurance policies or lack of time with patients, as
reasons to leave clinical practice (Pathman et al., 2002).
Many
complex reasons underlie this frustration with addressing social
issues. Vast wealth disparities undoubtedly foment feelings of learned
helplessness, as gaps between rich and poor or health and illness become
mortared into mortal logics of common sense. But perhaps one
explanation for the insecurity rests in Carmichael's argument: when
structural violence–systemic institutional stigmatization and
marginalization–is at issue, we train doctors to listen to
individualized stories, not to structural ones. For instance, methods
such as cultural competency or narrative analysis teach doctors to
better listen to the “cross-cultural” aspects of the stories that their
patients tell at moments of clinical encounter and within the context of
doctor-patient interactions. While such approaches enhance clinical
dialogue in vital ways, they do little to address the complex
relationships between clinical symptoms and social, political, and
economic systems. We thus argue that medical education needs to more
broadly engage with knowledges and methods beyond its traditional
purview if it wishes to train its practitioners to effectively address
the pressing health issues of our time. And, ultimately, that increasing
recognition of the ways in which social and economic forces produce
symptoms or methylate genes then needs to be better coupled with medical
models for structural change.
