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

ABSTRACT

Structural 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.

KEYWORDS:

• Collective health
• Latin American social medicine
• structural competency
• social determinants of health
• social determination of health

Introduction to structural competency

Recent years have seen a renewed interest in ‘structural approaches’ within the health professions (Sommer & Parker, 2013). During the past several years, researchers, scholars, educators, activists, and practitioners have elaborated a new educational and practice framework called structural competency (Hansen & Metzl, 2019; Harvey, Neff, et al., 2022; Metzl & Hansen, 2014; Metzl & Roberts, 2014; Neff et al., 2017, 2019, 2020). In the early years, the development of this framework took place almost exclusively in the U.S. More recently, scholars and practitioners have reinterpreted, challenged, and adapted aspects of the framework to different contexts around the world (e.g. Campanera et al., 2023; Castro & Alarcón, 2023; Friedner, 2023; Harvey, Neff, et al., 2022; Moscoso et al., 2023; Orr et al., 2022; Orr & Unger, 2020; Piñones-Rivera et al., 2019; Piñones-Rivera et al., 2022; Piñones-Rivera et al., 2023; Rodríguez-Cuevas et al., 2023; Szilvasi & Saitovic-Jovanovic, 2023).

This framework seeks to train health professionals – from physicians to nurses to mental health providers, social workers, physical therapists and even health policymakers and public health practitioners – to recognise and respond to disease and its unequal distribution as the outcome of social structures, which have been conceptualised as policies, laws, systems, and institutions, among other ‘structural’ phenomena, and the interlocking systems of oppression from which they often arise (Taylor, 2017). While the concept of the social determinants of health that predominates in the anglophone health professions emphasises the importance of social conditions to health outcomes, structural competency pushes analysis further ‘upstream’ to consider those social structures – in the form of systems, policies, and institutions – that give rise to and inequitably pattern the health-relevant social conditions along axes of class, race, gender, sexuality, nationality, and citizenship status, among others.

Structural competency employs various concepts to help trainees analyse the role of structures in health outcomes, as well as strategies for responding to them. For example, the concept of structural violence is used to ‘[describe] social arrangements that put individuals and populations in harm’s way’; ‘they are structural because they are embedded in society’s political and economic organisation and violent because they result in injury’ (Farmer et al., 2006). The concept of structural racism is incorporated to convey the ways in which inequities affecting racialised groups emerge from policies, institutions, and laws that benefit some groups, while harming others (Dean & Thorpe, 2022; Metzl & Roberts, 2014).

The concept of structural humility prompts health professionals to listen to and follow the priorities of the patients, communities, and collectives with whom they work instead of using their professional status (or even their structural competency training) in ways that reproduce professional/non-professional hierarchies (Metzl & Hansen, 2014; Neff et al., 2019). The concepts of symbolic violence (Bourdieu, 2001) and ‘naturalising inequality’ (Holmes, 2013; Neff et al., 2020) refer to the ways in which forms of structural violence are ignored, minimised, or legitimised, often by reference to presumably inherent biological, behavioural, or cultural differences among groups (Castañeda et al., 2015; Holmes et al., 2021). The naturalisation of racial inequities provides a paradigmatic example, as spurious appeals to cultural pathology or assumed biological deficit have long been used to elide the role of harmful social structures – and the racist ideologies from which they arise – in producing inequitable health outcomes (Roberts, 2014). Finally, structural competency calls for structural interventions that involve collective action to alter or abolish inequitable social structures and/or establish equitable ones (Neff et al., 2020; Nelson, 2011; Reich et al., 2016).¹

The framework of structural competency can be situated in a centuries-long effort to properly attend to the social, political, and economic drivers of health inequities. Many of the contributors to the framework draw on and are involved with European and North American social medicine movements, which recognise that the origins of disease are often found in pathogenic forms of social and political organisation, rather than solely individual behaviour or decontextualised biological pathology (Holmes et al., 2020; Rosen, 1947; Stonington et al., 2018). Given this understanding, addressing disease necessitates political action to alter and reshape social organisation (Carrasco et al., 2019). However, to date there has been relatively little engagement with the Latin American Social Medicine and Collective Health (hereafter LASM-CH) movement,² which represents a rich tradition of political activism and practice, community-engaged scholarship, and theoretical innovation toward health equity (Harvey, Piñones-Rivera, et al., 2022). Despite the shared goals of structural competency and LASM-CH to analyse and alter those social structures or structural processes responsible for health inequities, there have been few attempts to put these literatures into conversation and explore how they might inform each other (cf. Martínez-Hernáez & Bekele, 2023), including how the younger framework of structural competency can learn from the long-standing LASM-CH movement. To bound this article, we consider LASM-CH insights from Jaime Breilh’s new article in this special issue as well as his recently-published book, Critical Epidemiology and the People's Health, both of which synthesise a large body of LASM-CH scholarship.

Latin American social medicine and collective health

Jaime Breilh’s Critical Epidemiology and the People’s Health is the first book-length, English-language treatment of the LASM-CH movement, its history, and several of its most important theoretical innovations. Breilh’s article in this special issue brings together many of the insights from LASM-CH and puts them in relation to medical ethics and human rights. As many have noted (Krieger, 2011; Waitzkin et al., 2001), anglophone scholars have largely neglected the contributions of LASM-CH to epidemiology, community health, social theory, and public health practice, with some notable exceptions (c.f. Birn & Muntaner, 2019; Briggs & Mantini-Briggs, 2009; Castro, 2023; Harvey, Piñones-Rivera, et al., 2022; Holmes et al., 2014; Krieger, 2003, 2011; Porter, 2006; Tajer, 2003; Vasquez et al., 2019, 2020; Waitzkin, 2005; Waitzkin et al., 2001). Although the reasons for this are manifold – including neo-colonial hierarchies in knowledge production, and the methodological, linguistic, and geographic chauvinism that those hierarchies entail – the fact that this literature is almost entirely untranslated from the original Spanish and Portuguese also presents a barrier to engagement among non-Spanish and non-Portuguese speaking audiences. For these reasons, Breilh’s new article and book are significant contributions and important resources for equity-focused anglophone health researchers, educators, activists, policy-makers, and practitioners.

LASM-CH is a movement of scholars, researchers, practitioners, and activists throughout Latin America dedicated to health equity. While the movement has taken different forms in different countries based on regionally-specific social, political, and economic conditions, many who are involved have a strong dedication to theoretical innovation, theoretically-informed empirical research, as well as social and political action aimed at protecting health and advancing health equity through structural change (Vieira-da-Silva, 2021). As Breilh describes concisely in the first chapter of his book, the movement came into being in the 1970s and today is organised under the Latin American Social Medicine Association (Asociación Latinoamericana de Medicina Social [ALAMES]), which was founded in 1984 (Breilh, 2021), its country-level chapters, as well as by prominent country-specific organisations, like the Brazilian Association of Collective Health (Associação Brasileira de Saúde Coletiva [ABRASCO]).³

However, the movement has deeper roots in work by Latin American thinkers, including–but not limited to–Eugenio Espejo, Manuela Espejo, José Mejía Lequerica, Ricardo Paredes, Ramón Carrillo, Juan Cesar Garcia, Sérgio Arouca, Cecília Donnangelo, and Salvador Allende, and also in work by those associated with the nineteenth-century European social medicine tradition, such as Friedrich Engels, Louis-René Villermé, and Rudolf Virchow (Breilh, 2021). Breilh’s periodisation of the development of this movement is a rich resource on its own, and a very helpful jumping-off point for those interested in exploring the many references Breilh provides to other important works in the LASM-CH tradition. While work associated with nineteenth century European social medicine might be familiar to readers of Breilh’s text, for many in the anglophone context, the rich history of Latin American thought on issues of health, imperialism, capitalism, colonialism, indigeneity, and inequity, among other topics, will be new.

The LASM-CH movement’s long history of theoretical rigour, innovation, and critique cannot be overemphasised (Sesia, 2023). Those within the movement draw on a broad critical social theoretical base to examine the relationship between society and health. Marxian theories of political economy, social reproduction, the labour process, and health are prominent (Laurell, 1989); so too are theories of gender and health (Tajer, 2012). Additionally, there is considerable engagement with indigenous thinking, ontology, epistemology, and cosmovision, as discussed below in reference to the work of Breilh (2021 and in this issue). The movement has produced incisive critiques of prevailing public health models, practices, concepts, and related epidemiological paradigms. For example, those in LASM-CH have interrogated concepts like risk (Ayres, 2005; De Almeida Filho et al., 2009), health promotion (Czeresnia & Freitas, 2006), social participation (Menéndez & Spinelli, 2006), epistemology and subjectivity (Samaja, 2004), and static, non-dialectical understandings of health and disease (Menéndez, 2009), proposing instead a ‘health-disease-care process’ model to capture the dynamic, dialectical nature of these phenomena. Breilh has been a significant contributor to many of these theoretical innovations and critiques (Breilh, 2010). Most importantly for the purpose of this paper are his articulation of the social determination of health paradigm and his application of the related concept of subsumption to health (described below). These concepts help health care, public health, and global health scholars, activists, and practitioners to understand the shortcomings of prevailing biomedical, public health, and epidemiological paradigms. For those interested in a deeper understanding of these topics, we especially recommend the second chapter of Breilh’s new book (2021).

Social determination and the subsumption of health

The social determination of health paradigm was first proposed by Breilh in 1977, long before the advent of the social determinants of health concept that was popularised by Wilkinson, Marmot, and–later–many others (Wilkinson & Marmot, 1998, 2003). The social determination paradigm emerged in response to the prevailing epidemiological paradigm that, according to Breilh, neglected the underlying, complex, historical processes that shape and interrelate society and health outcomes. Instead, the mainstream form of epidemiology practiced and advocated within the global north and by western academics adopted a more narrow empiricist understanding of health that uses sophisticated quantitative methods to identify causal conjunctions among measurable social and behavioural phenomena (i.e. ‘risk factors’) and population health outcomes. By adopting this, in Breilh’s words, ‘Cartesian logic’, mainstream epidemiology concerns itself with what Breilh calls the ‘tip of the iceberg’ empirical domain, while eliding analysis of the social processes that illuminate how those empirically observable ‘risk factors’ are produced. According to Breilh, this limited focus of mainstream anglophone epidemiology and public health ‘disguis[es] the social relations of those empirical facts’ that epidemiology seeks to convey (2021, p. 136).

In other words, mainstream epidemiology focuses on specific variables and relates them to health outcomes without recognising or explaining the social processes acting historically that produce those variables in the first place, nor the broader social formation (‘i.e. social relations, modes of social reproduction (wealth production and accumulation), and metabolism with nature’ [Breilh, 2021, p. 95]) of which those variables are only an abstracted part. The shift from determinants to determination thereby requires a proper historicisation and theorisation of the social determinants of health (Harvey, 2020; Harvey, Piñones-Rivera, et al., 2022). While mainstream public health and epidemiology might focus on empirically-observable social determinants of health (i.e. health-relevant social conditions) and structural competency brings additional focus to their ‘upstream’, structural origins in inequitable policies, laws, systems, and institutional arrangements, the social determination of health paradigm supersedes this ‘upstream to downstream’ causal logic. Instead, the social determination of health paradigm situates these social-structural phenomena – and the epidemiological patterns that arise from them – within dialectical and interrelated social processes operating over historical time. For Breilh, these include the centuries-long process of capital accumulation under capitalist political economy, colonialisation and the ongoing process of neo-colonialisation, and humanity’s evolving relationship with nature and the exploitation of natural resources, what Breilh calls ‘society-nature metabolism’ (Foster, 1999; Schmidt, 1981).

Breilh links these historical processes with present-day epidemiological patterning through the concept of subsumption. The notion of subsumption is borrowed from Marx, who wrote about the ways in which the labour process came to take on different characteristics under different forms of political economy. That is to say, work – its form, features, and demands – are subsumed or conditioned by the broader political economic system. In this way, subsumption is used to refer to the ways less complex systems or processes are conditioned or structured by more complex systems within which they are embedded. Breilh proposes a series of nested domains – the general, the particular, and the individual – along which subsumption operates to condition social organisation and, by extension, epidemiological patterning (see especially Breilh, 2021, Chapter 2, pp. 89–113).

The most complex ‘general’ domain comprises those historical macro-social processes mentioned previously. They condition the subsequent ‘particular’ domain, which ‘comprises group-differentiated patterns of life that exist along social hierarchies’, including ‘shared consumptive practices, working conditions, incomes, and environmental conditions of particular social groups across social categories like class, racial or ethnic group, and gender’ (Harvey, Piñones-Rivera, et al., 2022). The particular domain conditions the least complex ‘individual’ domain, which ‘comprises individual “styles of living”⁴ … , such as “an individual’s capacity to organise actions in defense of health” (Breilh, 2021, p. 125), their material resources, formal membership in organisations, subjectivity, identity, beliefs, values, and individual ecological settings’ (Harvey, Piñones-Rivera, et al., 2022). This process of subsumption across general, particular, and individual domains ‘concomitantly conditions the phenotypic, genotypic, and psychological processes of an individual’ (Breilh, 2021, p. 110) and defines social reproduction, or the perpetuation of a social order, along with its epidemiological patterns, over time. This process of subsumption across these three domains constitutes a core part of the social determination of health paradigm. This carries profound social and political implications for locating responsibility for health inequities, and for informing collective action aimed at altering these processes. For readers interested in how these concepts might be incorporated into research programmes and interventions, Chapter 3 of Breilh’s recent book may be especially clarifying (2021).

For further exploration of all of these concepts, Breilh’s Critical Epidemiology and the People's Health is a groundbreaking contribution to health equity scholars, practitioners, and activists – and especially those who have not been able to access these concepts in their original Spanish and Portuguese. It provides one of the most sustained English-language treatments of many concepts and theories that have incubated over decades in Spanish- and Portuguese-language LASM-CH journals, regional conferences and symposia, and in their application in research programmes and practice. This novelty can at times feel overwhelming to the reader, especially if they are new to the LASM-CH tradition and the work of Jaime Breilh. For them and others, it is perhaps helpful to mention that many parts of the book easily ‘stand on their own’ as introductions to important topics from the LASM-CH tradition. For this reason, we might recommend reading sections of the book to get a relatively brief and comprehensive overview of a topic, and skimming sections that might feel less relevant or less readily understandable. We found ourselves skipping forward and backwards to review or preview material, as well as consulting other work by Breilh and LASM-CH scholars whom Breilh cites as we prepared this and other recent articles (e.g. Harvey, Piñones-Rivera, et al., 2022). We also recommend Breilh’s article in this special issue, in which he briefly summarises his proposal for critical epidemiology, and uses it to rethink and subvert the assumptions of bioethics and the right to health.

Dialogue between structural competency and Latin American social medicine / collective health

Theorising social structures as social processes

An important aspect of Breilh’s social determination paradigm is its focus on specific social processes, including capital accumulation, colonialisation and neo-colonialisation, and the society-nature metabolism that characterises humanity’s relationship with nature. This could be helpful in informing structural competency’s focus on social structures, which the literature has characterised in various ways. Harvey, Neff, et al. (2022) along with Neff et al. (2020) use the term social structure to refer broadly to laws, policies, systems, and institutions, as well as the harmful social forces and ideologies from which they arise, such as racism and capitalism. The influential 2014 article by Metzl and Hansen (p.129) states that structure,

implies the buildings, energy networks, water, sewage, food and waste distribution systems, highways, airline, train and road complexes, and electronic communications systems that are concomitantly local and global, and that function as central arteries in some locales and as sclerotic corollaries in others. Structure also demarcates the oft-invisible diagnostic and bureaucratic frameworks that surround biomedical interactions, and that potentially shape the contents there within. And, structure connotes assumptions embedded in language and attitude that serve as rhetorical social conduits for some groups of persons, and as barriers to others.

This expansive, somewhat diverse conceptualisation of social structure has proven to be an accessible and effective pedagogical tool to prompt trainees to think beyond the limited social determinants of health concept. Rather than focus on abstracted health-relevant social conditions (i.e. what are commonly referred to as the social determinants of health), trainees in structural competency are prompted to identify those laws, policies, institutions, and systems that are responsible for producing specific health-relevant social conditions.

At the same time, trainees have noted that such a broad and diverse focus on social structure has led to analytical confusion. Recent research evaluating the effectiveness of a structural competency curriculum among medical students and physicians found that among trainees and trainers alike, structure ‘operated as a near totalising category’, with one interviewee stating, ‘Structure is anything beyond the single person’ (Burson et al., 2022). Moreover, the diverse structures (and forms of structural violence) described by the structural competency framework are often presented more or less on an equal level and without definitive relation to each other. Again, this lack of specificity may serve some important pedagogical goals for new trainees. However, this broad definition of structure and the absence of a more specified framework for explaining health inequities within structural competency could constitute a limitation to the dissemination and application of the framework and might contribute to the overwhelm among trainees described by Burson et al. (2022).

In response, structural competency could benefit from learning from the social determination paradigm, which provides a level of analytic specificity in its explanation for how particular social processes (e.g. capital accumulation) subsume less complex processes, which in turn give rise to particular social structural conditions and epidemiological patterns that characterise health inequities. The focus on processes could also be seen to invite more of a focus on how the processes can be redirected, resisted, and changed. The word, structure, can be seen by some as durable and unchangeable. However, given that all structures (social and otherwise) are, over time, constructed, reinforced, defended, challenged, changed, and sometimes destroyed, a more processural understanding of structures could better capture their dynamic nature. To this end, structurally-attuned theories can be clarifying and thereby empowering tools for explaining, confronting, and changing the structural processes responsible for health inequities (see also Agénor, 2020; Bowleg, 2012; Ford & Airhihenbuwa, 2010; Harvey, 2020, 2021; Hatzenbuehler, 2018; Krieger, 2021; Minkler et al., 1994; Phelan et al., 2010). By defining social structures in such a way that they explicitly include historical social processes, structural competency could convey a historically-dynamic notion of structure that is attendant to the specific social processes emphasised by Breilh. In addition, by historicising present-day social structures in the context of dynamic social processes, structural competency could foster an understanding among trainees of the contingency of social structures, how they are historically produced, and ultimately how they might be challenged, acted on, and altered or abolished. This specificity could reduce trainees’ confusion and overwhelm when trying to conceptualise the nature of social structures, how they are related to each other, their relation to broader social processes, and how they can be changed.

Beyond ‘tip of the iceberg’ empiricism

Breilh has argued that simply replacing the ‘social determinants of health’ with what is intended to be the more ‘upstream’ notion of ‘structural determinants of health’ does not necessarily break from the empiricist, Cartesian, social epidemiological causal paradigm that the social determination of health paradigm critiques and seeks to supersede (Breilh, 2013). This is a useful insight for structural competency, which sometimes utilises the notion of ‘structural determinants of the social determinants of health’, but that also seeks to avoid the Cartesian reductionism identified by Breilh. To the extent that structural competency relies on a narrow notion of structure that is necessarily empirically observable (e.g. a welfare policy or a health care system) and placed in a statistical relationship with ‘downstream’ social determinants of health (e.g. access to social welfare services or access to health care, respectively), it risks neglecting the deeper social processes of subsumption operating historically and contemporarily that give rise to these ‘tip of the iceberg’ social and structural determinants of health (Harvey, Piñones-Rivera, et al., 2022). That is to say, by simply moving further ‘upstream’ (i.e. from the social to the structural), one may still rely on a limiting and conservative notion of causality that can foreclose critical insights into the social structural and processural nature of health inequity.

By embracing a broader theoretical framework or paradigm, which for Breilh and many others in LASM-CH is the social determination of health paradigm, analysis can properly account for these determinative, but not always readily observable, social processes that subsume or condition our social world. In short, according to the social determination paradigm, while some social processes are readily observable, others are obscured but nonetheless empirically observable with the appropriate methods, and some are not accessible through traditional empirical methods yet nonetheless fundamental in producing our social, political, and economic worlds, along with the health inequities that emerge from them. In this issue, Breilh (2023) develops one particularly helpful example on the ways in which capitalist society has historically invested vast resources to position a Cartesian-functional theoretical-methodological approach that leads us to understand bioethics as an essentially individual and medical challenge.

In conclusion, considering the benefits of the LASM-CH focus on processes as historical and changeable, we recommend that scholars, practitioners, and collectives utilising the framework of structural competency consider transitioning the focus of their analysis to ‘structural processes’. In this way, the framework contributes to a move toward structural analysis and responses in anglophone movements for health equity while maintaining a focus on the historicity, theory, contingency, and alterability of social structures.

From critique of cultural competency to critical interculturality

Structural competency retains an ambiguous relationship to the notion of culture on account of its historical development. The framework emerged in part as a critique of mainstream versions of the cultural competency framework, which initially sought to train health care providers about the health-relevant cultural practices of their increasingly diverse patient populations in the US context. Over time, cultural competency has been criticised for its conceptualisation of culture, including – among other things – its treatment of cultures as static and as an essentialising ‘list of traits’ that sometimes relies on stereotypes that could constitute forms of racism (Jenks, 2011; Kleinman & Benson, 2006; Tervalon & Murray-Garcia, 1998). Moreover, by focusing disproportionately on culture and cultural difference for explaining why some are sick and others are healthy, cultural competency risks ignoring more determinative political and economic drivers of health, as well as harmful social forces like racism, sexism, and socio-economic inequality (Gregg & Saha, 2006; Viruell-Fuentes et al., 2012). Training in structural competency has importantly emphasised that these appeals to cultural difference to explain health inequalities can constitute a form of ‘naturalising inequality’, whereby structurally-generated health inequities are elided or made to seem normal and deserved (i.e. emerging from one’s vaguely-defined ‘culture’) rather than produced or imposed and unjust (e.g. Holmes, 2013; Holmes et al., 2021). However, in treating the concept of culture as relevant only to the extent that it is used to naturalise inequality, structural competency has had little else to say about how cultural processes might be taken into account among those dedicated to health equity.

Within LASM-CH, a critical interculturality has been developed to recognise cultural differences and forms of cultural hierarchy and oppression, as well as to facilitate dialogue among different cultural world-views. For Breilh, interculturality rejects simplistic notions of cultural relativism and calls for long-term efforts among different groups to put diverse cultural perspectives, priorities, and meanings in conversation while resisting hierarchy in order to marshal culturally-specific practices, beliefs, knowledge, narratives, epistemologies, ontologies, and cosmovision in the service of collective political projects for liberation (Breilh, 2021; Harvey, Piñones-Rivera, et al., 2022; Horton, 2023). Within Latin America, this was prompted specifically by long-term collective movements to develop equitable terms of engagement, with priority given especially to indigenous groups. In his article in this issue, Breilh links interculturality and ethics through a ‘metacritical perspective’⁵ that seeks to learn from conceptualizations of the good life, including South American indigenous Sumak Kawsay-Ali Kawsay, South African Ubuntu, Indian Swadeshi and Chinese Minzhu, fair living from human rights, and the good, gendered life of feminist movements, to name a few.

This is far from a straightforward process and cannot be achieved by simply learning about diverse cultural groups and their health-relevant cultural beliefs or practices. But it does provide those concerned with health equity and collective action in the political realm an impetus for recognising and working across cultural difference while countering social (including colonial and settler-colonial) hierarchies in a way that is entirely distinct from the limited cultural competency framework. In the context of structural competency, the concept of critical interculturality could represent an approach to culture that includes, yet also goes beyond, critique and provides a vision for engaging cultural difference in an anti-colonial manner while working for social change and health equity.

In the context of the structural competency framework, interculturality could build on the concept of structural humility, understood to be the stance of listening to and following the lead of patients, communities, and neighbourhoods in analysing and responding to structural violence (Metzl & Hansen, 2014; Neff et al., 2020). This stance counters the common assumptions of expertise among health professionals that often serves to silence local, community knowledge and instead seeks to highlight the wisdom of communities and the actions that they are already taking for health equity and social justice. Drawing on critical interculturality, this understanding of structural humility can acknowledge and respect cultural difference, work against coloniality in its various forms, and actively work toward health equity in solidarity across difference. Critical interculturality can also be an opportunity for structural competency to recognise the anglophone North American framework of cultural humility, proposed as an alternative to cultural competency as an ongoing process of self-reflection and praxis that acknowledges social hierarchy and inequity (Tervalon & Murray-Garcia, 1998). We suggest that conversations between structural competency, structural humility, critical interculturality, and cultural humility can benefit each of these concepts.

Examples of structural interventions from Latin American social medicine and collective health

Although structural competency training involves learning about past structural interventions and imagining future structural interventions that act on, abolish, or otherwise alter extant structures, some evaluations of these trainings have shown an ‘uncertainty about how to act on structures’ among medical student and physician trainees (Burson et al., 2022). Researchers have found that when structural interventions are articulated by physicians and physicians-in-training, they often focus on the individual working within a clinical setting, rather than, for example, participation in long-term collective action beyond the hospital or clinic (Burson et al., 2022). Indeed, the question of ‘What is to be done?’ in response to harmful forms of social organisation does not always have obvious answers. However, the history of LASM-CH provides illustrative examples of health workers collectively engaging in social, political, and economic realms to bring about changes to social structures and processes.

For example, those involved in the LASM-CH movement played a central role in Brazilian health care reforms in the 1980s, which culminated in the establishment of the ‘Unified Health System’ (Sistema Único de Saúde), a universal, publicly-administered, publicly-financed, and community-based health system with a focus on primary care that attends to upper- and lower-class patients alike. This bucked prevailing neoliberal reform efforts of the time that encouraged the cultivation of private health insurance markets for those who could purchase such products, and underfunded, poor quality, and insufficient public services (i.e. only ‘cost-effective’ and ‘essential’ services) for those who could not (Laurell, 2003).

Laurell (2003) describes another example of the Mexico City government’s approach to health. After the elections in 2000, the Mexico City government was run by the left-wing Partido de la Revolución Democrática, while the federal government was controlled by the right-wing Partido de Acción Nacional. Despite this political climate, the Mexico City government undertook drastic social and health reforms based on ‘the recognition of the intrinsic and equal value of all [people], which obliges the government to honor and protect alike the life of all human beings’ (Ibid.). These entailed redistributive and reallocative public programmes based on principles of equity and collective health, rather than cost-effectiveness. One such programme was the ‘Program of Food Support and Free Health Services and Drugs for Senior Citizens’, which comprised a monthly cash transfer for food and universal access to health care services within government facilities.

In the wake of Pinochet’s dictatorship in Chile, the Popular Education on Health Foundation (Educación Popular en Salud [EPES]), has worked to create community health teams by training health promoters in the areas most impacted by the dictatorship’s neoliberal economic restructuring and by drawing on existing social organisation that persisted despite the dictatorship's repression of social movements. EPES has worked with groups whose grassroots initiatives focus on resistance and survival, such as collective kitchens, human rights solidarity groups, and women's groups, all of which were part of the slow process of re-articulating a movement against the dictatorship. For EPES, health problems are a social and political issue, so the health promoters’ role is to do preventive and educational work focused on community organising to defend health rights. Grounded in Paulo Freire’s concept of popular education, EPES values the knowledge of people in impoverished communities, so the analysis of community needs and work plans are always based on that knowledge. EPES focuses on forming health groups that are linked to broader struggles, that possess autonomy, and that build lasting organisation in order to become social protagonists to transform reality through collective action (See Anderson et al., in press).

The LASM-CH tradition emerged in the context of health workers responding to political repression and violence, sexism, neo/colonialism, poverty and inequality, imperialism, failing state infrastructure, and oppression against different social collectives, including indigenous communities (e.g. Breilh, 2021). Throughout the history of the LASM-CH movement, its participants have organised political coalitions, used state power toward equitable ends, and challenged harmful ideologies, such as colonialism and neoliberalism. As such, work by the movement’s participants can be a useful resource for providing tangible examples of structural change. And by highlighting structural interventions from outside the US context (cf. Harvey, Neff, et al., 2022), structural competency can embrace a more global and internationalist vision for its application.

Future conversations among paradigms for social and health equity

We are convinced that ongoing conversations among movements and paradigms for social and health equity around the world are important and promising. In this article, we seek to outline some insights from LASM-CH paradigms and movements, especially as highlighted by the current article and recent book by Breilh. We recognise that there are many other important paradigms and movements for social justice and health equity around the world and hope this article encourages further exchanges. Due to historical and contemporary geographic and linguistic chauvinism from the anglophone context toward the academy in Latin America, we have focused especially on insights that structural competency–developed originally in anglophone contexts–can gain from LASM-CH. In ongoing conversations with Jaime Breilh and others in Latin America, we recognise that there are also insights from structural competency that might inform specific questions and problematics in LASM-CH. We have heard from some interlocutors that the focus on clinical interactions and on institutional production of health inequities and of their legitimisation may be a helpful impetus for scholars and practitioners in LASM-CH. We encourage other scholars, practitioners, and collectives interested in and working toward social and health equity to push forward dialogues between different traditions and paradigms. Movements for social justice and health equity are incredibly important in the contemporary world and have unrealised opportunities for mutual sustenance, inspiration, critique, and solidarity.

Conclusion

Structural competency – and other frameworks related to health equity – can learn a great deal from engaging the rich body of literature that has emerged out of the LASM-CH movement. More work is needed to disseminate the important contributions of LASM-CH scholars and practitioners among English-speaking audiences and beyond. With the publication of Breilh’s article in this special issue as well as his book, Critical Epidemiology and the People's Health, anglophone public health, global health, and other health professional audiences have access to in-depth explanations and analyses of this movement and some of its core theoretical insights.

Those involved in structural competency and other frameworks for health equity around the world can gain a great deal from the social determination of health paradigm as well as the concepts of subsumption and critical interculturality, which together provide an alternative approach for pursuing health equity that foregrounds the importance of specific interrelated processes in the production and maintenance of – as well as resistance to – social and health inequities. This focus on specific, related processes highlights the ways in which social and health inequities have been produced, could be otherwise, and can be changed. We recommend that scholars and practitioners working within the framework of structural competency consider changing their focus of analysis toward ‘structural processes’ to clarify this historical and future contingency. Interculturality, then, brings insights from South American solidarity movements centred by indigenous communities to push all movements for health equity to work together respectfully across cultural differences toward collective forms of liberation. LASM-CH provides powerful examples not only of concepts that are useful for understanding and confronting social and health inequities, but also of successful social movements and policy changes for social and health equity. In order to avoid repeating past mistakes and engaging in geographic and cultural chauvinism, anglophone public health, global health, medicine, nursing, allied health professions, and health policy researchers should engage with and learn from the LASM-CH movement and the rich literature it has produced. We hope this article plays some small role in such a change.

Disclosure statement

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

Additional information

Funding

This work was supported by European Research Council [grant number 101045424]; National Science Foundation [grant number 2121144]; Regular Fondecyt [grant number 1210602].

Notes

1 Although fluency or proficiency in these concepts is core to structural competency, there is some controversy about the use of the term ‘competency’. Structural competency seeks to be legible to and incorporated in health professional education, which is increasingly accredited as ‘competency-based’ (in a similar way that ‘cultural competency’ has been made legible and incorporated). At the same time, there is a sizable critical literature on competency-based education pointing out its relationship to reductionism, utilitarianism, the fragmentation of knowledge, and neoliberal restructuring of labour markets (Chauí, 2018; Frank et al., 2010; Hirtt, 2008, 2009; Ramos, 2013; Touchie & Ten Cate, 2016; Whitcomb, 2016). While we recognise these critiques, we see the use of the term ‘competency’ strategically, seeking to incorporate critical social analysis into education in ways that are resonant with instructors, course designers, and accrediting bodies. In this way, using the term ‘competency’ can be understood as a counter-hegemonic strategy, in a context hegemonized by the competency-based education model. Structural competency’s aim to support an ongoing process of learning, action, and reflection that is done in collaboration with and in support of collectives and social movements works against the limitations and ideological assumptions of competency-based health professional education.

2 Two special events to put structural competency and LASM-CH in conversation more explicitly were held under the auspices of the PhD programme in Collective Health, Environment, and Society of the Universidad Andina Simón Bolívar (Quito). The first was the International Seminar: ‘Forced displacement and health: Perspective from collective health’, held in Quito on December 14–16, 2022, with the participation of Seth M. Holmes, Carlos Piñones-Rivera, and Nanette Liberona. The second was the Colloquium ‘Rethinking Structural Competency’, held in Quito from March 21 to 28, 2023, with the participation of Seth M. Holmes, Michael Harvey, and Carlos Piñones-Rivera. In the meantime, an important dialogue has developed with Jaime Breilh and his doctoral students, leading to the creation of a Structural Competency track within the PhD programme at UASB.

3 These have nurtured academic programmes in LASM-CH, including a doctoral programme in Collective Health, Environment, and Society from the University Andina Simón Bolívar in Ecuador, a doctoral programme in Collective Health from the National University of Lanús in Argentina, a doctoral programme in Collective Health Sciences from Autonomous University of México in Xochimilco, México, a postgraduate programme in Collective Health from the Federal University from Rio Grande do Sul in Brasil, an undergraduate programme in Collective Health from Federal University of Bahía in Brasil, a master and a doctoral programme in Collective Health from Rio de Janeiro State University in Brasil, a graduate programme in Collective Health in the University of São Paulo, and the graduate programme in the Department of Collective Health of the State University of Campinas, to name just a few.

4 Note that Breilh’s ‘styles of living’ are distinct from, more contextual and less behavioural than ‘lifestyles’ in English. See the quotes in the text above of Breilh (2021 page 125 for more information on this distinction).

5 Metacritical entails the articulation of critiques: ‘a discourse of articulation with the discourses of others, but which does not claim to be a ‘matrix discourse’ or master narrative, a narrative that is unifying, as we have said before, but without being dominating, and which can orient emancipatory discourses that are around a common process of transformation of the object and subject of knowledge for health’. (Breilh, 2003, pp. 285–286).