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

ABSTRACT

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.

KEYWORDS:

• Structural competency
• health of immigrants
• structural violence
• social movements learning
• critical medical anthropology

As part of the emancipatory project of society, collective health implies the construction of an alternative power that must be articulated to the vital processes of popular organisations and movements. (Jaime Breilh, 2003)

1. Introduction

Structural competency proposals have been developed to ‘infuse clinical training with a structural focus’ (Metzl & Hansen, 2014, p. 126). By structure, we mean ‘durable patterned arrangements […] that produce and maintain social inequalities and health disparities, often along the lines of social categories such as race, class, gender, and sexuality’ (Stonington et al., 2018, p. 1959). This approach is necessary and politically significant given the limited presence of content related to structural approaches to stigma and health inequalities in medical education (Metzl & Hansen, 2014, p. 126) both in the US, where it was developed and worldwide.

However, the focus on medical education naturally emphasises the development of structural competencies in health workers, leaving aside community leaders and communities. In this article, we shift the focus to reflect on how the work of migrant community leaders may entail the development of structural competency and what can be learned from this complementary perspective. Our starting point is not how we develop such competency through formal training but what we can learn from the development of structural competency if we take seriously the reflexive, critical, and situated learning process of immigrants fighting structural violence. Our paper thus focuses on the development of structural competency that occurs ‘beyond the classroom.’

With this intention, we analysed the development of structural competency in a migrants’ rights organisation in northern Chile: The Open Assembly of Migrants and Pro-Migrants [Asamblea Abierta de Migrantes y Promigrantes de Tarapacá, AMPRO]. We conducted focus groups on AMPRO’s experience, convening migrant leaders who are part of the organisation. This exercise confirmed that, throughout its history of struggle, AMPRO has been developing structural competencies very similar to those covered in a formal structural competency curriculum. We also noted the achievement of competencies not included in canonical structural competency proposals, that we believe to be fundamental in the fight against inequity in the health of migrant populations.

This article first presents a brief history of the organisation and its context and then outlines the development of the structural competency achieved by the organisation. We also reflect on specific components of competency that go beyond the usual framework, introducing the concept of collective structural competency. Finally, we propose ways to move beyond some of the limitations of the common medical-centred approach when thinking about structural competency.

2. The open assembly of migrants and pro-migrants

Chile is a transit and destination country for south-south migration. Between 2015 and 2020, Chile received approximately 1 million immigrants, nearly three times the estimated total for 2015. Some 1,462,103 immigrants were living in Chile by the end of 2021. Seventy-nine per cent of the estimated immigrant population comes from other Latin American countries, mainly Venezuela (30.7%), Peru (16.3%), Haiti (12.5%), Colombia (11.4%), and Bolivia (8.5%) (INE-DEM, 2021). This estimated percentage represents 7.5% of the total population living in Chile and only considers regularised persons or those who have been in this administrative category. This is an important distinction, as there has been a significant increase in unauthorised entries during the pandemic and the Venezuelan exodus.

A new Migration and Foreign Services Law (Law No. 21.325) was enacted in 2021. Despite establishing a series of principles based on human rights, it is highly restrictive. This legislation has been analysed as discriminatory and as limiting the migrant population’s ability to achieve legal status by preventing them from changing status once they are in Chile (Liberona et al., 2022). The social rights to which Chile’s migrant population has access are quite limited and depend largely on acquiring legal status. There are barriers to access to healthcare (Piñones-Rivera et al., 2022) and education, and migrant children and adolescents tend to enrol in school less frequently than their Chilean peers (Rojas, 2022).

The Open Assembly of Migrants and Pro-Migrants developed in this context. AMPRO is an autonomous non-profit entity whose origins date back to 2015. It comprises migrants and local residents from different backgrounds who work to protect migrants’ rights, including the right to healthcare.

AMPRO is a social organisation that does not set specific roles for its members. However, six migrant leaders represent and lead their communities of Bolivian, Ecuadorian, Colombian and Cuban nationals or, more broadly, the Tarapacá Region’s immigrant community. The non-migrant activists involved in AMPRO include trainees in fields such as social work, anthropology and psychology, contributing critical technical and communication skills. Both migrants and non-migrants participate in specific activities and projects through AMPRO.

The entity works with organisations, associations, unions, institutions, and independent individuals regardless of nationality. It has been part of the National Network of Migrant and Pro-Migrant Organisations [Red Nacional de Organizaciones Migrantes y Promigrantes] since 2017. AMPRO works in the Tarapacá Region, providing social, legal, migration, and labour support, psychosocial and health care, and support for migrants’ rights. It also develops educational and cultural activities with local populations, especially those who live in and commute through the cities of Iquique and Alto Hospicio.

AMPRO was created due to a series of experiences that shed light on the problems and needs of the migrant population in the Tarapacá Region. Its leaders participated in dialogues with political authorities that led to the drafting of a report detailing the need for immigration law. Between 2015 and 2016, migrant organisations and academics organised a series of discussions on the bill. These sessions led to forming a group, which later became an organisation. Unlike most migrant associations in the region, AMPRO fights for migrants’ rights instead of focusing on cultural affairs.

A critical milestone in the entity’s history was the violent eviction of approximately 1,200 families in 2016. Most of those impacted were migrants living in the Toma de La Pampa settlement. Scholars were asked to help address the psychosocial problems experienced by the families who were evicted and relocated to unhealthy sites. That was the beginning of long-term collaboration. Legal actions to protect the evicted population were filed, and issues related to housing and unhealthy conditions were presented to the Interior Ministry’s Migrant Advisory Council, the Chilean Health Ministry, and the United Nations Special Rapporteur on the Right to Adequate Housing. The critical psychology collective ‘Sembrando Dignidad’ also got involved and conducted various psychosocial support interventions based on the information gathered through the local census ‘Buen Vivir Sin Fronteras’ (Liberona & Piñones-Rivera, 2020).

AMPRO was founded in early 2017 at the first meeting of the National Network of Migrant and Pro-migrant Organisations in Valparaíso. In 2018, AMPRO created the Joanne Florvil Spanish School for Haitian Nationals in cooperation with Chile’s largest trade union organisation, the CUT (Central Unitaria de Trabajadores). It also positioned itself in the local media by disseminating solidarity activities and communiqués denouncing rights violations and injustices. In 2019, AMPRO was strengthened by the connections that it forged with new organisations such as the Migrant Women’s Movement of Tarapacá and the Association of Feminist Lawyers (ABOFEM). These new partnerships helped it become networked in diverse ways during the 2019 protests known as the estallido social and during the COVID-19 pandemic. This allowed the organisation to support migrant families through solidarity-based food initiatives (ollas comunes or community kitchens) in addition to the usual socio-legal care.

In 2020, AMPRO began to provide various forms of assistance to the migrant populations most affected by the pandemic, organising donation campaigns and delivering food to soup kitchens and ollas comunes in various communities in Iquique, Alto Hospicio, and Colchane (on the Chilean-Bolivian border). Its members also conducted sexual and reproductive health workshops in collaboration with feminist groups. In 2021, AMPRO’s work focused on providing legal counsel for an exceptional migratory regularisation process during the Piñera administration. AMPRO members helped hundreds of families in person despite the restrictions due to COVID-19.

AMPRO members also provided food, water, shelter, medicines, and other supplies to displaced Venezuelan families who entered Chile in large numbers during the border closures implemented during the pandemic. The extreme conditions of their arrival in Chile and the national authorities’ failure to meet their needs caused this population to be stranded in the streets of Iquique, forming camps in city squares and on beaches. Local scholars engaged in an interdisciplinary effort to assess the healthcare needs of the Venezuelan migrant population in Iquique’s Plaza Brazil to identify the structural violence to which they were subjected (Liberona et al., 2021). This report shed light on the severity of the situation and activated networks. The entity is currently working with various other organisations to develop projects. It has partnered with the Popular Health Education Foundation (EPES) in the field of healthcare; the Alquimia Fund in the field of gender equality; and the Homosexual Integration and Liberation Movement (MOVILH) to support migrant sexual diversity.

3. Materials and methods

This article reflects on the collaborative work conducted within AMPRO, placing its scope, emphasis, and assumptions in critical dialogue with the parameters of the structural competency framework. We explore the existence of structural competency within this organisation, which has not undergone a formal training process in this area but focuses on structural interventions (Metzl & Hansen, 2014).

We conducted two focus groups (Bonilla y Escobar, 2017; Cameron, 2005; Krueger, 2006; Sullivan & Foltz, 2000) on AMPRO’s experience that included leaders of different nationalities (Ecuadorian, Colombian, Bolivian, etc.). To facilitate the dialogue and streamline the process, we used the tools included in the Structural Competency Working Group Training Program (Neff et al., 2020). We read and discussed the definitions of Social Structure, Structural Violence, Structural Racism, Structural Vulnerability, Naturalization of Inequality, Implicit Frames, and Structural Humility included in that training programme (Neff et al., 2020). The resulting dialogue was transcribed and analysed to investigate AMPRO’s development of structural competency. Consequently, the following subsections have different lengths, depending on the amount and depth of data that emerged during the focus groups. We used an inductive coding strategy to identify other components of competencies that we propose as important to include in the framework of ‘structural competency.’

Our research is based on collaborative activist ethnographic research, which is defined as ‘a systematic study based on work and cooperation with others, using the self as an instrument of knowledge to reach the ‘depth’ of ethnography, in a particular sociopolitical process, with which the researchers identify and commit themselves’ (Stephen, 2012). Collaborative research places us in a contractual relationship and engages us in a political commitment to a collective actor (Paris Pombo, 2012, p. 258). The authors of this text are members of or have collaborated with AMPRO at different times and on different activities (providing inputs, drafting documents and projects, developing technical reports, etc.). Our connection to the entity facilitates information gathering. As Stephen stated: ‘Collaboration produces conversations, contributions and forums that foster additional exchanges’ (2012, p. 232), enhancing the quantity and quality of the data.

The study was conducted in accordance with the Helsinki Declaration and was approved by the Universidad de Tarapacá’s Scientific Ethical Committee for studies involving human subjects (Approval Code N°35/2021). Informed consent was obtained from all subjects involved in the study.

4. Results and discussion: The development of structural competency beyond the classroom

In the sections that follow, we evaluate the degree to which the objectives of a structural competency curriculum are met. We have organised the data following the order of the objectives presented in Neff et al. (2020), incorporating quotations that illustrate their fulfilment.

4.1. Identifying the influences of structures on patients’ health

AMPRO has developed a capacity to identify structural violence (Farmer, 2004; Farmer et al., 2006; Galtung, 1969) through its experiences working to counter it. Based on the pathways included in the Structural Vulnerability Assessment Tool (Bourgois et al., 2017), we can argue that AMPRO has developed an awareness of how discrimination, lack of solid legal status, residency, and economic insecurity impact migrants’ health. Our work also has allowed us to identify Chilean institutions and their structural racism as essential sources of harm (Liberona & Piñones-Rivera, 2020; Piñones-Rivera, Liberona, Muñoz & Holmes, 2022a).

AMPRO participants can explicitly identify how discrimination affects health problems. They understand that this process operates at the interpersonal and institutional levels. For example, one migrant leader in AMPRO stated,

Healthcare itself is not good for everyone. That is our starting point. What is the difference? Migrants are impacted three times as much as others when it comes to healthcare, and that rate is even higher in the case of women because we are hypersexualised and idealised as … as a source. Although we are told that it is good for immigrant women to enter the country because the Chilean population is ageing, we are restricted regarding birth rights. It is as if to say: some children, yes; some characteristics of women, yes; some characteristics, no. It is even worse for afro-descendant or indigenous migrants.

There is also a clear awareness of how institutions segment healthcare according to criteria such as social class, ethnicity, gender, and nationality. In the context of the neoliberal multiculturalist policies of the Chilean State (Piñones-Rivera, Liberona, Muñoz & Holmes, 2022a; Piñones-Rivera et al., 2017), intercultural health has become a mechanism of segregation of health care under racialised criteria. According to several Structural Competency authors, this is one of the negative results of the Cultural Competency framework (Metzl & Hansen, 2014; Metzl & Roberts, 2014). As another migrant leader put it,

In many ways, they are forced to classify themselves. For example, I have seen a lot of Aymara people denied care at the doctor’s office. They are told that they have to go to a traditional healer. Why? Because they are wearing long skirts, in the case of women […] You start thinking, ‘Do you stop being a doctor? Because a doctor is not interested in how patients dress … I have to care for my patient. I am responsible for what I do.’. The same happens with other migrants: ‘No, you take care of them.’ In other words, they cannot diversify and understand that medicine has to be an open field, regardless of the patient. My job is to get this person healed, not target them based on their skin colour, dress, where they come from, or if they are poor or rich.

While AMPRO has championed the cause of critical interculturality, this advocacy has never made invisible the structural processes that are at the root of inequity, unlike what does occur in the context of (neoliberal) intercultural health policies in Chile (Piñones-Rivera, Liberona, Muñoz & Holmes, 2022a; Piñones-Rivera et al., 2017).

4.2. Identifying the influence of structures in the clinical encounter

We found something similar regarding the influence of structures on the clinical encounter. Experiences and reflections emerged regarding racism in healthcare involving the assumed hyper-sexualisation of migrant women and the asymmetry in the doctor-patient relationship with the assumption that health professionals are always right. Importantly, migrant leaders recognised that all accounts are experiences of structural violence, many of which relate to medical negligence. The harrowing experiences of migrants include such practices as removing the uterus without consent or failing to provide treatment for hypoxia when delivering a baby. The main violent structures are racism and a biomedical hegemony that underlies the arrogance of healthcare providers who refuse to consider the patient’s point of view and knowledge in the care process (Cognet & Montgomery, 2007; Fassin, 2000, 2002; Gee & Ford, 2011; Liberona & Mansilla, 2017; Piñones-Rivera et al., 2022). In the words of one AMPRO leader,

Furthermore, we found that in 2009 and 2010, many immigrant women had unnecessary caesarean sections or had their uterus removed. This was the case with Patricia. My cousin married a Colombian woman, and the physician removed her uterus. It was not until a year later that she realised they had removed her entire womb. Moreover, the doctor said that she was undocumented even though she was in the process of regularising her status. She did not want to testify because she was afraid. Nobody wanted to testify. The hospital told her that it was her word against the physician’s. How many other people have faced similar problems?

4.3. Generating strategies to respond to the influences of the structures in the clinic

AMPRO members have developed several intervention strategies based on the experiences mentioned above. However, most are not aimed at the clinical field. The main clinically oriented strategy involves supporting migrants’ efforts to assert their healthcare rights. The organisation has called attention to migrants’ situations, particularly those of undocumented migrants. Chile’s Health Ministry Circular N°. A15/06 authorises medical care for pregnant women and minors in medical emergencies regardless of their migratory status. However, migrants still routinely experience denial of care. In some cases, migrants have been forced to report themselves¹ to receive medical care, which is illegal (Cabieses et al., 2021; Liberona et al., 2021). An AMPRO leader explained, ‘We have practically had to go with the printed law in hand and say, look, Article 2 says that every migrant has the right … With the documents, handing out the papers, providing that support’.

4.4. Generating strategies to respond to the influence of structures beyond the clinic

AMPRO migrant leaders have done a great deal of work in this area, assessing and responding to the influences of structures beyond the clinic. For this reason, this section is the most extensive, as it deals with a large part of the competencies developed by AMPRO in its struggle for the right to health. Progressively, AMPRO was able to connect this extra-clinical space with clinical interactions and their impact on their health. Over the years, multiple components of structural competency have been developed and incorporated to address the structural conditions affecting migrant populations. Some components relate to AMPRO’s internal organisation, work distribution, and the incorporation and consolidation of different roles needed to defend migrant rights. Others are more focused on AMPRO’s relationship with the external entities they establish alliances or confront to resolve situations of structural violence. We will separate these two areas to explore these components further, as described below.

4.4.1. Competency related to the constitution and internal operation of AMPRO

4.4.1.1. The creation of a protected space for the circulation of experiences and knowledge

We believe that a critical condition for the other components of structural competency is the ability to create a space of trust and dialogue in which experiences can be shared, recognised, validated, and emotionally contained. This protected space allows AMPRO to organise and carry out actions that counteract structural violence.

The space that AMPRO offers thus plays two roles. The first is sharing experiences, which are generally related to the administrative inefficiencies of the state bureaucracy, labour abuses, difficulties in accessing healthcare or education, and indignation in the face of racism displayed, for example, in the authorities’ speeches and beyond. Creating a protected space allows migrants and their advocates to share these experiences, validating them and recognising them as part of an unfair collective reality, a fundamental issue in the face of the culture of silence (Freire, 2012, p. 156) that can deny the existence of these violations of rights.

This validation takes place in an empathetic environment that fosters a feeling of familiarity among AMPRO members, which is fundamental to understanding the persistence of these structures over time, as explained by one AMPRO member,

In the end, we are like a family … it is not only an institution where you can say, ‘Oh look, I am leaving, and I will never talk to you again.’ No. We share and try to maintain that closer bond. I have no words to describe what we have become over the years. So that has also allowed the people to say, ‘Ah I feel at home; they have treated me so well that it makes me want to come back’. That gives you new meaning as well.

As the literature on social movements learning has shown (Hall, 2006; Kilgore, 1999), ‘solidarity draws individuals to engage in the group process, and the group becomes more confident of itself as a collective change agent’ (Kilgore, 1999, p. 197)

Additionally, this space allows members to share how they cope with their problems. The first and probably most crucial example is the acquisition and transmission of legal knowledge. This knowledge is mainly used to address the large numbers of migrants who are out of status and have become increasingly visible due to forced migration from Venezuela. These insights have arisen from their experience facing a bureaucratic, opaque system that systematically produces irregularities (Álvarez Velasco, 2017; De Genova, 2002, 2005). People share successful and unsuccessful experiences in an effort to confront the difficulties encountered by newly arriving migrants. ‘For situations like that, we have also had to prepare ourselves and say, ‘Well, my friend, look, this happened to me, and that is it … and this is what you have to do if this happens to you’. This flow of information helps knowledge develop and circulate: ‘In one way or another, while some of us are more systematic than others, we all have been learning. For example, Juana is the master of referrals, and I handle them and refer them to Juana. We all consult with each other and find the best option for the family or person we are assisting.’

4.4.1.2. Coordinating a heterogeneous group of agents

The nature of the problems that AMPRO addresses (social, labour, political, legal, psychological, among others) require different types of knowledge. As such, AMPRO’s leaders partner with professionals and students of disciplines like psychology, anthropology, law, social work, agronomy, and architecture. AMPRO members also have focused on learning how to help migrants by engaging in formal and informal education processes. This has led many of AMPRO’s leaders to enrol in technical-professional or university programmes or to engage in informal learning. Such efforts are generally guided by a desire to find solutions to the problems faced by migrant communities. AMPRO is not based in academia but in ‘the vocation of the people’. In the words of one AMPRO leader,

I believe that the essence is the commitment of the people there. Because, as Laura says, there are situations, there are academics, there are universities, but the base is the people, right? and they have a vocación [calling] because there is no AMPRO without it.

As such, one of AMPRO’s strengths is coordinating its diverse agents around efforts to address structural problems. AMPRO does not organise its efforts around different academic disciplines but integrates popular knowledge and different disciplines to solve specific problems. AMPRO engages in a practical interdisciplinary and intercultural praxis (Breilh, 2021) based on the need to solve migrants’ problems. As we saw in the vignette, AMPRO’s base is migrant people and their commitment to improving their living conditions in contexts of structural violence. As one member explained,

I believe that all of this has allowed us to be one of the strongest organisations here in the north, one of the most prominent organisations. We have lawyers. We have everything. We are not the typical functional organisation with a secretary and a treasurer that go to dances and meals, and that’s it. We want to teach ourselves. We want our staff to educate themselves. We want them to have the tools to provide the benefits of social organisations to other people.

4.4.1.3. Conducting research

Over time, AMPRO has increasingly engaged in efforts to conduct research. Research arises from the need to present data that objectively show the lived experiences of migrants (Liberona, Piñones-Rivera et al. 2021). It guides our reflections and actions and is an asset in our relationships with other organisations and authorities. AMPRO’s first significant research experience was the Buen Vivir Community Census, described in the book Violencia en la Toma (Liberona & Piñones-Rivera, 2020). Our capacity to conduct research has been nourished by projects developed through AMPRO’s resources and the support provided by the students and professionals who collaborate with AMPRO or form part of its network of allies at the national and international levels.

It is important to emphasise that AMPRO members understood that research is not the prerogative of professionals or academia. This made it possible to develop collective experiences and capacities regarding how to organise data production, distribute roles, generate participatory analysis and disseminate results. This research has never been detached from AMPRO’s needs; on the contrary, it has always been based on these needs and has pursued the means to resolve them. Over time, a research focus on structural factors has become more robust.

4.4.2. Structural competency in AMPRO’s relationships with other entities

This subsection describes and analyses AMPRO’s relationships with other entities. We cover partnerships with other organisations and relationships with officials that AMPRO develops as part of its efforts to protect migrant rights.

4.4.2.1. The creation and operation of networks

AMPRO has learned the importance of networking at the local, national and international levels in order to work for structural change. The association networks primarily with base organisations that advocate for migrants and provide assistance at the local level. These include several self-managed organisations such as Las Kabras, La Inclusive, and Colectivo 18 de Octubre. Some organisations have done significant work directly influencing healthcare; feminist organisations such as Colectiva Aquelarre and Profesoras feministas have helped AMPRO understand and address issues related to obstetric violence and the control of sexual and reproductive life.

Networking at the national level has been a crucial part of AMPRO’s work since its origins as part of the National Network of Migrant and Pro-migrant Organisations of Chile (https://www.facebook.com/redmigranteschile/). Collaboration at the national level has allowed AMPRO to receive assistance in essential areas (legal, denunciation campaigns, fundraising, etc.) from organisations with significant experience and knowledge (e.g. the Movimiento de Acción Migrante -MAM from Santiago). This networking has also allowed relationships with international organisations, such as the National Day Labourer Organizing Network. These relationships have allowed AMPRO to work more effectively for structural change in solidarity with other migrant organisations.

The two most critical elements that safeguard such partnerships have been transparency in reporting the use of donations and the continuity and relevance of the work with the migrant population maintained regardless of difficulties such as the COVID-19 pandemic.

4.4.2.2. The use of technologies to provide services

AMPRO has learned a great deal about the benefits of using technology to aid migrants. In this case, WhatsApp (Figure 1) has served as an open and fully accessible platform for contact, delivering information, and providing social, legal, and emotional support. Because it protects privacy and confidentiality, it has allowed the entity to earn migrants’ trust gradually. Two AMPRO members discussed that process:

D: Yes, five WhatsApp were created for 1,500 people.

C: Really?

D: Yes, this WhatsApp system was created at the end of 2019 during the estallido social to assist when several government offices were burned in Santiago and papers were lost. We were already ahead of the game because we saw that the Jesuit Migrant Service’s MigrApp platform was insufficient because it was too bureaucratic. ‘Hello, go to the page, bye.’ Question and answer … done! Nothing else? […] So, we wanted to create a system that was a more direct tool that everyone could use. So, we created a WhatsApp group with a former AMPRO colleague, which was a personalised tool for us. Each member can answer questions and organise the information […]. We have been able to help people, and interestingly, this was not created only for Iquique … we provide services to people nationwide and even to people abroad who want to come back. They ask questions through WhatsApp and get the information they need. It has worked, and we have seen that it is a more personalised tool; people are more confident to talk, and people like that we talk to them with empathy, too. People often talk to us because they feel there is a person who can also accompany them psychologically.

Figure 1. AMPRO WhatsApp announcement.

4.4.2.3. Socio-legal impact capacity

AMPRO has participated in several legal battles to promote the rights of migrants. These include filing motions for protection against the eviction in the Pampa settlement (Liberona & Piñones-Rivera, 2020), motions against collective expulsions, and motions before the labour courts (e.g. the case of the appeal filed on behalf of Haitian worker Kecy Sylvain), and claims to the comptroller’s office [contraloría] for failure to comply with the deadlines and regulations established by the State.

AMPRO’s legal work has been a vital tool in the fight against rights infringement and institutional racism. The goal is to counteract the violence the State systematically exercises against migrants. Each case that the organisation wins sets a precedent that raises the legal standard at the national level, which is an important task. However, AMPRO members have had to engage in a learning process to do this work. They have developed technical skills, both formally and informally and made use of connections with specialists through local, national, and international networks.

4.4.2.4. The capacity to make visible: Advocacy communication

Advocacy communication (Wilkins, 2014) forms a significant part of AMPRO’s work. It involves designing and disseminating communications campaigns that address critical contemporary issues (e.g. the anti-immigrant march in Iquique in 2021). Some of these campaigns counter the reproduction of racist and xenophobic rhetoric in the mainstream media.

Advocacy work also helps to disseminate AMPRO’s work, conveying information about its activities, fundraising campaigns, and projects. The need to make it visible is related to the organisation’s need to qualify for funds. In the words of one AMPRO leader,

Initially, we were reluctant to upload photos because we wanted to protect people’s dignity. However, we understood … how we could validate our work without uploading more material? This led to the creation of a team focused on these types of efforts.

Of course, an ethical discussion arose at that time, which led AMPRO to disseminate its work through photographs showing only AMPRO’s migrant leaders, avoiding the exposure of the faces and identities of the other participants.

4.4.2.5. Maintaining autonomy from the humanitarian market

Over the years, and even while engaging in collaborative efforts, AMPRO has maintained its autonomy from the humanitarian market (Carbonnier, 2015). Following Carbonnier (2015), we use this expression to note that international humanitarian assistance is a growing market involving total funding of $24.5 billion in 2014. AMPRO has maintained its autonomy from this market partly due to its economic independence, since their members are workers who earn income outside the organisation. In the words of one member,

We all have different jobs, and nobody here is specifically focused on this work. We give the time we can, but we all work, which is also a characteristic of the organisation. Other people are making a living from this, but not us. We all have different jobs, so it does not affect us when people say that we profit from this. We come when we can and try to maintain our connection to people.

Contrary to what some might believe, this approach has not jeopardised the organisation’s continuity or assistance to the migrant community. Quite the opposite, when resources were scarce during the pandemic, and such support became critical, AMPRO remained active, organising monetary donations and supplies and aiding migrants, even without a permanent physical space.

AMPRO’s critical stance towards governmental institutions, including migration agencies (IOM, UNHCR, and Red Cross, among others), has allowed it to maintain its autonomy regarding the guidelines derived from these organisations. For example Figure 2:

E: We would not call them organisations. They are structured corporations. There are several, but the financial aspect always dominates.

D: We are the only organisation that has never stopped doing this work. We have not said, ‘I have COVID’, or ‘We cannot do that because we have a schedule’ … . We have responded to situations on the spot, especially in Alto Hospicio and now with Laguna Verde, in Iquique.² We have even gone to Pozo Almonte, to towns in the highlands … even other organisations such as Servicio País have contacted us so that we can provide counselling. So, we have not stopped; we are the only ones who have kept going.

Figure 2. AMPRO meeting.

4.4.2.6. Bypassing multiculturalism

The State is one of the most important actors that AMPRO has to interact with. Accordingly, one of the main competencies developed involves responding critically to State strategies characteristic of neoliberal multiculturalism (Díaz Polanco, 2007; Hale, 2002; Piñones-Rivera et al., 2017). AMPRO has developed critical perspectives on how the State governs through participation, how the State translates the problems that affect migrants into a culturalist language, and how the State renders invisible the role played by social and political-economic structures in the production of all of these problems. This constitutes the contextualised learning of the competency to translate cultural aspects into structural ones, and therefore, it is consistent with the shifting from cultural to structural competencies (Metzl & Hansen, 2014; Neff et al., 2020).

First, there is an awareness that multiculturalism involves the risk of restricting migrant incidence to the ‘cultural’ space:

L: No. It is good for eating, dancing, parties or apthapi³ -that is what it is good for. We are all multicultural. But when it is time to make known our demands, to propose these conversations, they tell us ‘no’. It is like they are saying, ‘You have crossed the line. In other words, we continue to classify migration as a food entity, labour entity, or dance entity but not as a reference or entity that can meet and say, well, let us talk about these issues that currently have complex implications for us.

Migrant participation tends to be relegated to artistic-cultural and culinary activities.

Second, government agencies restrict immigrants’ political agency. AMPRO members are clearly aware of this, developing analyses that include the following:

• Only the most like-minded or least critical leaders are allowed to participate;

• Government agencies seek to control participation in order to limit criticism;

• When controlled in this way, participation becomes legitimisation and validation of the government’s actions;

• Training does not go down to frontline workers (including, for example, security guards);

• The State expects leaders to volunteer to solve government problems but refuses to invest resources to cover related costs (e.g. food, transport);

• Migrant organisations shoulder the burden of addressing highly complex problems associated with migration;

• The State fails to provide sufficient time to efforts to enhance participation (e.g. 3 h for training); and

• These entities fail to question Chileans’ violence towards migrants and naturalise institutional racism.

Finally, AMPRO has demonstrated that this type of multiculturalism also emphasises migrants’ responsibilities for this situation, pushing the violation of rights into the background and reproducing the status quo.

L: People talk a lot about migrants failing to meet their responsibilities. Yes, that is fine, but what about the State’s obligations to us? What are the State’s responsibilities to us? We hear a lot about duty but not about rights. There are no legal rights! Duty, duty, duty! You even see it in institutional brochures … in SJM [Jesuit Migrant Service] and UNHCR [United Nations High Commissioner for Refugees] brochures. The institutions never say ‘knowledge can be transferred’ -they never say anything like that. We create that when we make our flyers. In other words, their position is very biased.

4.5. Collective structural competency

So far, we have shown how the praxis of an organisation fighting structural violence involves the development of structural competency. This includes identifying the influences of structures on patients’ health, identifying the influences of structures on the clinical encounter, and generating and implementing strategies to respond to structures in the clinical setting and beyond it. This last point has been AMPRO’s focus and has fostered competencies related to its constitution, internal functioning, and relationships with other entities. The most important of these are the creation of protected space for the circulation of experiences and knowledge; the capacity to coordinate a heterogeneous group of agents; the ability to conduct research (and not just be the object of research); the creation and operation of networks; the development of socio-legal impact capacity; the capacity to make its work visible; and the capacity to maintain autonomy concerning ideological production (in this case, the humanitarian market and neoliberal multiculturalism).

By observing and analysing the development of structural competency in an organisation like AMPRO, we can move away from an individual and professional approach and consider the existence of collective structural competency. The competencies we have shown and analysed are structural because they involve the ability to understand how structural violence produces impacts on healthcare inside and beyond the clinical space and the ability to intervene effectively in different spaces and at different levels (Metzl & Hansen, 2014; Neff et al., 2019; Neff et al., 2020). However, those competencies are collective because they do not correspond to the individual. For example, the ability to identify the influence of structures on patients’ health had as a condition the collective competency to generate a space of trust and dialogue to share, recognise, validate and emotionally contain experiences, and organise and implement actions to counteract structural violence. This does not depend on developing individual competencies, as they are collective competencies gradually developed in relationships within the organisation and with other agents in the social and political work for structural change.

As Freire (1979) has argued, ‘Conscientisation cannot exist outside of ‘praxis,’ or rather, without the act of action-reflection’ (p. 15). A practice oriented towards the struggle against structural violence like that of AMPRO naturally produces processes of consciousness raising, leading to the development of structural competency. This kind of structural competency does not belong to individual knowledge but to social knowledge (Menéndez, 2002, p. 290).

Moreover, the adjective ‘collective’ does not only refer to the supra-individual. It evokes the sense present in Latin American Social Medicine of being ‘part of the emancipatory project of society, […] implying the construction of an alternative power, which must be articulated not only around academic or institutional efforts -which almost always end up serving power- but on the vital processes of popular organisations and social movements’ (Breilh, 2003, p. 32).⁴

In closing, we will highlight two final aspects of the concept we are proposing here. First, unlike the usual concept of structural competency, these skills are not acquired through ‘training’ (Metzl & Hansen, 2014, p. 2) but developed through praxis. Praxis is the action that transforms reality (in a political sense) and, as Freire (1979) and Breilh (2003, 2021) have shown, it entails the dialectical transformation of the subject.

The second and most fundamental point is that the development of these collective competencies is guided by actors’ need to protect and improve their living conditions. Health professionals are called to collaborate with community leaders from an ethical position called structural humility (Camacho & Rivera-Salgado, 2020; Metzl & Hansen, 2014; Neff et al., 2020). We agreed that it is essential to be cautious because, as Breilh has noted, academic and institutional efforts frequently end up serving power (2003), mainly because professional training tends to depoliticise people by turning them into technical experts (Rivera Colón, 2019, p. 27).

The recognition of this political problem in medical education is probably one of the central paradoxes of the structural competency proposal. Any training (including training in structural competencies) may be part of a system of the legitimisation of knowledge and practices that contributes to the production and reproduction of the position of professionals in society. In concrete terms, whenever training in structural competencies is ‘certified’ in some way, a quota of power could be understood to be granted to actors who have already accumulated important quotas of power in the social hierarchy. The recognition of these power dynamics is what makes essential and critical the development of structural humility, which consists precisely in teaching health professionals to recognise and counteract power hierarchies between themselves and patients as well as communities. And consequently to recognise and support the knowledge and power that community members have; and to follow and accompany in solidarity those community members instead of leading and seeking further power.

As an attentive reader would have noted, structural humility is not a competency developed at AMPRO. This makes sense because the people most affected by structural violence do not need to be humble about their experiences. On the contrary, migrant leaders have learned to recognise the value of their experiences, practices and knowledge in the struggle against structural violence, against daily forms of disqualification and naturalisation exercised by symbolic violence (Bourdieu & Wacquant, 1992; Holmes, 2013; Piñones-Rivera et al., 2018).

So, what is the complementary concept of structural humility when we focus on community members and leaders? We will not provide an answer here, but we want to point out some lines of reflection. First, important traditions of thought have addressed this problem outside of medical education. Just to mention two examples, in community psychology, there is the crucial Latin American reflection on community strengthening [fortalecimiento] processes (Montero, 2003); likewise, community social work has developed important critical approaches through proposals such as participatory action research (PAR), one of whose leading developers was the Colombian sociologist Orlando Fals-Borda (Bonilla et al., 1972). Recognising those contributions does not mean that it is not necessary to broaden the frameworks from which these processes are thought, including the crucial contributions of Structural Competency, because, in the training and practice of both social workers and community psychologists, the structures are relegated to the margins, in favour of individualised analysis and intervention (Downey et al., 2019). The same happens within the medical profession itself, even though there are fundamental contributions such as those of Jaime Breilh, who redefined the entire field of relations between scientific knowledge and popular and indigenous knowledge through the call for decolonisation, whose horizon is the development of a counter-hegemonic metacritical perspective (Breilh, 2003, 2021).

Our point is that future developments will be favoured if these traditions, especially those developed outside of English-speaking environments, are integrated into reflection and praxis. Grounded in that critical tradition, we suggest that the current focus from health professionals and medical education can be complemented by recognising the collective structural competencies developed in community leaders and community organisations while reflecting on structural competency. This may be an excellent point from which to keep developing ways to fight against structural violence.

5. Conclusions

Various scholars have criticised the dependence of competency-based education on the market (Hirtt, 2008, 2009), including its reductionism, utilitarianism, the fragmentation of knowledge it produces, its promotion of the lowest common denominator, etc. (Chauí, 2018; Frank et al., 2010; Touchie & Ten Cate, 2016). Students have argued favouring a broader justification for education focused on structural intervention than the term ‘competency’ might ordinarily suggest (Donald et al., 2019, p. 45). We have noted that one way forward is a concept that moves away from the individualism implicit in the cognitive model of competency-based medicine towards the development of collective structural competency in communities rather than individuals. We need structurally competent communities. Individual health workers can be (and are) part of such communities, so we propose an approach that focuses primarily on the collective.

The next step in developing collective processes related to structural competency is to enhance our understanding of how obstacles to developing structural competency are political rather than cognitive. The main issue produced by the hegemonic medical model (Menéndez, 1984, 2005) is not cognitive (it does not incapacitate one’s ability to think or imagine other alternatives). It is instead political in nature in that it ideologically shields depoliticisation and legitimises an environment (institutional, financial, etc.) in which political involvement becomes unfeasible (in terms of cost–benefit) and superfluous (by limiting it to a labour market). In short, it becomes an idealistic and irrational remnant. In arguing that the problem is political, we assert that the main problem is not how to prepare individuals to imagine or even carry out political actions that account for the development of a particular ability but how to create and sustain collectives that embody a political commitment, and take from the collective experience and resources the tools to fight against structural violence.

To answer this question, we must develop concepts such as collective structural competency, which simultaneously shifts the focus from medical professionals and the individual level, appealing to a collective health perspective (Breilh, 2019, 2021; García, 1972; Lemos, 2010; Ramos, 2001a, 2001b) on structural competency. The development of structural competency in training for healthcare professionals is an important step forward. In this article, we argue that to develop healthy communities, it will be important to work toward complementarity between healthcare professionals trained in structural competency – including structural humility – praxis and strong community organisations working in collective structural competency praxis.

Acknowledgements

This article is the result of the Regular Fondecyt project 1210602: Refugio en Chile y densidad del tránsito. The authors thank Seth M. Holmes for his support and for being a constant inspiration for our work.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Fondo Nacional de Desarrollo Cientifico y Tecnologico: [Grant Number 1210602].

Notes

1 Autodenuncia means that the migrant is forced to report themselves to an official as out of status.

2 This refers to a fire that occurred on January 10th of this year at the Laguna Verde settlement in Iquique, Chile. https://www.biobiochile.cl/noticias/biobiochile/videos/2022/01/10/incendio-en-campamento-laguna-verde-de-iquique-deja-al-menos-tres-viviendas-afectadas.shtml

3 Aymara word that implies the collective sharing of food according to principles of reciprocity.

4 See also Martín Baró (2006).