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- Convenors:
-
Mirko Pasquini
(University of Gothenburg)
Margret Jaeger (Vienna Social Fund Education Centre)
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- Discussant:
-
Seth M. Holmes
(University of Barcelona, ICREA, UC Berkeley)
- Formats:
- Roundtable
- Mode:
- Face-to-face
- Sessions:
- Tuesday 23 July, -
Time zone: Europe/Madrid
Short Abstract:
The roundtable fosters current scholarly discussion on the developing of a “Structural Competency” framework within Health Care Services facing multiple conditions of crisis. It contributes to conversations on decolonizing and democratising knowledge production in medicine and global health.
Long Abstract:
The crisis of healthcare services has been lately to the fore of global political agendas. The COVID 19 pandemic powerfully showed the disastrous consequences of emergency systems overcrowding, and the lack of equity in the distribution of funding, equipment and labor force to address the increasing needs of people with chronic health conditions. Working as a magnifying lens, COVID-19 also illustrated the iatrogenic effects of humanitarian and privatisation campaigns in the global south, the impact of mass incarceration on health in the US, or the increasing underfinance of welfare services in Europe.
Through the study of healthcare crisis, like the COVID-19 Pandemic, anthropologist have been able to reframe individual narratives of staff and patients into structural terms (Bourgois et al. 2017). Recent works in anthropology have explored what happens to health care staff possibility to deliver care (Kostakiotis and Trakas 2014; Morris 2018), and which kind of ethics and subjectivities are developed in a state of crisis (Luhrmann 2001; Smith-Oka 2021; Closser et al. 2022). To strengthen such contribution, the roundtable explores anthropology’s engagement with research and training of health care practitioners facing multiple forms of healthcare crisis.
Taking the structural competency research framework as a starting point (Metzl and Hansen 2014), we aim to problematise the capacity of health professionals to recognise and respond to the shifting role that social, economic, and political structural factors play in patient and community health. All of which by contributing to conversations on decolonizing and democratising knowledge production in medicine and global health.
Accepted contributions:
Session 1 Tuesday 23 July, 2024, -Sofia Bowen (Universidad Católica de Chile)
Contribution short abstract:
Reflecting on the complex challenges encountered by cancer healthcare professionals in Chile adopting the 'psychosocial' framework, this intervention explores implementing 'structural competency' within a context of limited resources, health inequality, and historical social injustice.
Contribution long abstract:
This intervention addresses the intricate decision-making, ethical, regulatory, and political challenges faced by healthcare professionals in Chile, with a particular emphasis on cancer care, while also extending its scope beyond this domain, adopting the 'psychosocial' framework endorsed by the World Health Organization. Chilean policymakers introduced this framework to address enduring health inequalities and social insecurity, caused by the implementation of neoliberal policies, by recognizing the psychological and social elements of health and disease. Although the policies recognize the social complexity of illness, which in theory includes structural issues, on the ground they mainly translate towards attention to psychological and cultural approach that emphasizes patients' lack of awareness or (‘erroneous’) cultural beliefs about illnesses and treatments, as well as the patient's responsibility for emotional recovery and adaptation. The key questions being explored include how psychosocial teams negotiate different ideologies, epistemes (ways of knowing), and legal frameworks during implementation. How do these practitioners and teams navigate ethical dilemmas as they recognise themselves as gatekeepers not only of healthcare services but also of rights and the acknowledgement of historical, political, and socioeconomic factors contributing to patients' suffering? Ultimately, the intervention aims to reflect on the challenges of implementing a "structural competency" approach in practice within a context of limited resources and historical and ongoing social injustice. This involves considering the broader societal and systemic factors that contribute to the "cancer epidemic" and general health inequalities, and exploring how healthcare practitioners can address these challenges in their day-to-day work.
Lucia Mair (University of Vienna)
Contribution short abstract:
Drawing on teaching experiences with medical students and healthcare professionals in Germany and Austria, I reflect on how structural competency invites discussion of crises of professional identity in healthcare, between medical professions and, crucially, across generations.
Contribution long abstract:
The current moment of crisis in healthcare services worldwide envelops not only overburdened health infrastructures, but healthcare professionals themselves. Not least since the global COVID-19 pandemic, healthcare workers increasingly show signs of burnout, depression, demoralization, and post-traumatic stress disorder (PTSD) in different global contexts, causing some to question their professional identity as healthcare workers, and leave healthcare entirely as a profession. In light of global shortages of physicians and nursing professionals, this is a worrying trend with tangible consequences.
Often overlooked, however, is the similarly prevalent issue of trainee burnout – among medical and nursing students - which poses a harm to students’ own (mental) health, to patients, and to strained healthcare systems in which students are educated and in which they work. In this roundtable, I would like to discuss in how far structural competency can serve as a framework to open up honest conversation about personal and collective crises of confidence in one’s own (medical) profession, and foster epistemic humility among young healthcare providers in particular. Structural competency significantly widens the scope of what falls within the remit of doctors and nurses to include social, political and cultural factors contributing to (ill) health - a move that can have the diverging effects of empowering, but also overburdening future healthcare workers even further. I offer to this discussion firsthand experience as a physician-anthropologist and health activist to highlight the entryways, but also the challenges I have encountered in working with the framework in healthcare education in Germany and Austria.
Zvika Orr (Jerusalem College of Technology) Eyad Abu Sara (hadassah mount scopus hospital) Mark Fleming (University of California, Berkeley)
Contribution short abstract:
This paper examines how healthcare leaders and institutions in Israel deploy discourses of medical neutrality and intervention to navigate the politics of judicial overhaul and war. We argue that a structurally competent medicine should account for political violence as a determinant of health.
Contribution long abstract:
This paper explores the meaning, manifestations, and ramifications of medical neutrality in conflict zones. Medical neutrality is a normative arrangement that differentiates a zone of clinical practice in which patients are treated impartially, and medical personnel are shielded from the demands of politics and conflict. We analyze how Israeli healthcare institutions and leaders variously deploy discourses of medical neutrality and intervention to navigate and take varying stances on the judicial overhaul and the war in Gaza, and how they represented the role of the healthcare system in society and during conflict. We find that healthcare institutions and leaders promoted a vision of the Israeli healthcare system as a neutral space of coexistence, while at the same time intervening into political affairs deemed to be within the realm of legitimate public debate. This analysis reveals how healthcare institutions use concepts of neutrality to protect their expertise and authority while also strategically intervening into political conflict. We suggest that a structurally competent medicine must explicitly recognize the normative arrangements of neutrality and intervention unique to the practices of healthcare institutions. Concomitantly, the conceptual framework of structural competency should be broadened to include conflict-related issues and address the needs of the victims of severe structural violence in conflict areas, thus promoting peace, health equity, and social justice.
Roberto Beneduce (University of Turin) Ibrahima Poudiougou (Norwegian University of Life Sciences)
Contribution short abstract:
The experience carried out at an ethnopsychiatric centre in Italy will be analyzed to explore what other idioms of suffering and registers of traumatic memory reveal, but above all the 'diagnostic racism' and the 'epistemic-clinical' injustice of health institutions in front of migrants' suffering.
Contribution long abstract:
‘A panther lives in my body’. ‘An invisible force hit me and made me fall’. Strange sentences like these are common among migrant patients’ narratives: they express at once clinical issues and different ontologies. The aim of this contribution is to interrogate the political, epistemological, and clinical dimensions raised by mental suffering in the immigrant population.
The experience carried out at an ethnopsychiatric centre, the Frantz Fanon Centre (Turin-Naples, Italy) is a formidable laboratory for exploring what is revealed by other idioms of suffering and registers of traumatic memory. However, the encounter between immigrants and and health care institutions is often marked by a specific form of structural violence. We suggest calling it 'diagnostic racism.' This notion aims to highlight the use of diagnostic categories and therapeutic practices despite the clinicians’ ignorance of the patients’ histories, the cultural significance of certain behaviors, or simply their language. These acts can be interpreted as a particular expression of 'white ignorance' (Mills, 1997).
Such issues form the backdrop to a more general clinical-epistemic injustice, due to a double denial: the failure to acknowledge the role of social exclusion and institutional racism in the genealogy of crisis and alienation, and the denial of our ignorance. These remarks are meant to emphasize the importance of such critical epistemology for the agenda of radical ethnopsychiatry, but also for global mental health programs. They want to highlight a particular kind of ‘cultural-structural competency’ (Hansen & Metzl 2014), able to articulate political, historical-anthropological, and clinical dimensions of suffering.
Amand Führer (Martin Luther University Halle-Wittenberg)
Contribution short abstract:
Social determinants of health are increasingly acknowledged as major driving force behind health inequities. At first glance, the concept looks very similar to the approach of structural competency. This contribution investigates the overlap between both concepts and discusses their differences.
Contribution long abstract:
The concept of social determinants of health (SDoH) aims to explain the differentials in health outcomes across populations. It does so by highlighting that environmental, economic and social factors are the main influences on individuals’ health, and that exposure to such (harmful or beneficial) factors depends in turn on wealth, education, place of residence, discrimination and other stratifying forces.
In practical terms, this implies that health professionals need to be aware of these determinants and consider them in their diagnostic and therapeutic reasoning. At first glance, one could therefore think that teaching SDoH automatically entails improving health professionals’ structural competency.
Still, at a closer look there are substantial differences between the two approaches in terms of epistemology, didactics and practical implications. My contribution will map these differences and explain why teaching health professionals about SDoH needs to be embedded in a broader framework of structural competency.
Hereby, I will show that the concept of SDoH lacks a clear epistemology and does not necessarily imply an emancipatory framework or critical reasoning. In addition, critical reflexion of researchers’ and health professionals’ positionality is not required to work with SDoH but is an integral part of structural competency.
Therefore, training health professionals in structural competency will look different from teaching SDoH, and will entail more critical self-awareness and an explicit epistemological grounding. By adding these elements to already existing curricula on SDoH, we can promote health professionals’ structural competency, increase their ability to address SDoH and overall improve the care patients’ routinely receive.