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Building Structural Competency in the Undergraduate Global Health Curriculum
Over the past five years, educational institutions have undergone a shift in the way they prepare students to think about diversity in medical and health settings (Dao et al. 2017). Since the late 1990s, the dominant “cultural competency” paradigm has emphasized instruction in “the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments” (Liaison Committee on Medical Education 2018, 11). In 2014, Metzl and Hansen articulated an alternative “structural competency” approach for US medical education, arguing that clinical interactions are shaped not just by cultural variables but also by “economic and political conditions that produce and racialize inequalities in health” (127). They define structural competency as
the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases . . . also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even the very definitions of illness and health. (2014, 128)
As social scientists, we appreciate the way that states of health and illness are shaped by the physical and social world around us—the houses and neighborhoods we live in, the racial categories assigned to us, the socioeconomic hierarchies of which we are a part, and the political histories of the lands in which we live. In this article, we wish to build on, adapt, and demonstrate the value of a structural competency framework, which has thus far been largely restricted to graduate education, in the context of undergraduate global health curricula.
We are particularly drawn to the corrective that structural competency can offer to programs designed to equip undergraduate students for work in lower-income countries. Our pedagogy draws on Metzl and Hansen’s framework to encourage students to “rearticulate ‘cultural’ presentations in structural terms” and to “shift diagnostic focus from the ‘culture’ of individual patients to the culture of privilege and oppression” (2014, 130). All too often, existing curricula frame difference in cultural terms (e.g., encouraging students to acknowledge “traditional” beliefs about health and healing) and emphasize gaps, absences, and deficiencies in local health landscapes (e.g., empty pharmacies, missing medical supplies, understaffed facilities, lack of education or awareness, etc.). We argue, instead, that students ought to understand poverty not simply as absence but as the presence and functioning of systems of inequality that are socially and historically produced. Additionally, a structural competency framework encourages us to shift our gaze from the problems of “traditional” culture to the construction of harmful and shortsighted discourses about “traditional” culture. We can think, for example, about how responses to West Africa’s 2014–16 Ebola epidemic were thwarted by pathologizing—instead of engaging with—cultural beliefs and practices around burial (Richards 2016).
We advocate for an expansion of the canon of global health instruction beyond problems, priorities, policies, and best practices to include attention to structure, which we think about in two complementary ways: (a) structural determinants of the uneven distribution of health and illness, and (b) the structural features of global health that shape how we understand, represent, and attempt to respond to illness and disease. While the former lens highlights the political, economic, and social causes of disease, the latter calls our attention to the social forces shaping public health systems and interventions. In other words, we make public health itself an object of study and train students to investigate how interventions reflect the contexts in which they emerged. We propose four anchoring concepts for a culturally competent undergraduate curriculum: colonialism, development, neoliberalism, and decolonization.
Structural competency requires that students recognize how global health problems and practices have taken shape in relation to more than five hundred years of capitalist expansion and the racialized subjugation of distant others. Conquest and dispossession, genocide, and the establishment of economies of extraction (best epitomized by the plantation and the mine) had wide-ranging consequences for the health of colonized peoples (see Packard 1989; Thornton 1987).
Disease directly threatened the colonial project, felling European and US administrators (Curtin 1998) and impeding the reproduction of labor for the colonial enterprise. In the late nineteenth century, efforts to protect the health of colonial agents and sustain an adequate labor force coalesced in the emerging field of tropical medicine (Anderson 2006). Colonial states also sought to control sexually transmitted infections among European administrators, settlers, and soldiers by regulating the movement of women in urban spaces and across lines of race and class (Manderson 1996). Coercive and military-style disease eradication and hygiene campaigns reflect these imperial origins (Amador 2015; Packard 2016). Missionary medicine offers a second origin story for contemporary global health (see Comaroff 1993; Kalusa 2007; Vaughan 1991). While their framing devices differed, missionaries’ interests in bringing up clean, well-behaved children who would become “proper” Christian subjects (Allman 1994; Summers 1991) aligned neatly with efforts by colonial capital to reproduce labor through nourishing and disciplining young bodies (Hunt 1988).
If health systems in lower-income countries are sometimes called “underdeveloped” and their populations are frequently thought of as “diseased” by their very nature, structural competency draws our attention to the production of ill health by transnational economies of extraction both past and present. Knowledge of early forms of public health intervention—and the multiple ideological projects embedded therein—helps students to understand contemporary inequalities in access to health care as well as enduring mistrust of health professionals in some settings. Structurally competent students will be equipped to situate conversations about patient rights, dignity, and agency in historical context and to think critically about contemporary global health actors’ aims and motives.
Development and Neoliberalism
Structurally competent students will recognize health as a field of practice within the broader international development sector, reciprocally influenced by the ideological shifts within it. An important starting point is understanding “development”—and discourses and practices to address “underdevelopment”—as a postwar project related to American capitalist expansion (Escobar 1995; Esteva 1992). The Bretton Woods Institutions (the International Monetary Fund and the World Bank) have played an important role in shifting ideologies, interventions, and investment priorities in public health. Neoliberalism—understood here as a trinity of deregulation, privatization, and responsibilization—deserves special attention, not least because trade liberalization and the loosening of labor and environmental regulations have been blamed for worsening health outcomes around the world (Kim et al. 2002). Equally as important are the ways neoliberal ideology informs global health technologies, from the introduction of user fees to newer calls for performance-based financing (Foley 2010; Keshavjee 2014; Turshen 1999). Some donors contribute to “basket funds” that pool resources to support developing country governments. Others, most especially the United States, have rerouted funds for global health away from the public sector, leading to the “NGO-ization” of health and development, in which aid agencies are accountable primarily to donors rather than to beneficiaries or citizens (Pfeiffer 2003; Turshen 1999). Finally, behavior change programs that urge citizens to make personal investments toward achieving better health and greater productivity—called “neoliberal responsibilization” (Rose 1996)—have been critiqued for obscuring the structural causes of ill health and for echoing historical efforts to shape colonized peoples into particular kinds of “proper” or compliant subjects.
Participatory and community-based approaches to primary health care offer an important corrective to the harms caused by top-down planning and may encourage approaches premised on solidarity and partnership (World Health Organization 1978). However, participatory interventions have also been critiqued as mechanisms for shifting responsibility and costs to those with the fewest resources while simultaneously romanticizing “community” (Morgan 2001). Health promotion strategies grounded in human rights offer an alternative to economic rationales for investing in health but, in some contexts, can erase local agency and perpetuate harm in the name of saving victims deemed sufficiently innocent or pitiable (Mutua 2001). Structural competency requires attention to how global health is informed by diverse ideological currents in development thought and practice and equips students to understand the complex and sometimes ambivalent consequences of health and development interventions.
Finally, structurally competent students will respond to the urgent need to decolonize global health and will work to disrupt assumptions that “expertise” naturally flows from technocrats in predominately white institutions in the Global North to black and brown people and communities in the Global South. This requires attention to the way that health and well-being are taken up by social movements, including movements for political reform and economic justice. Calls to decolonize institutions of higher education by the Rhodes Must Fall movement in South Africa, for example, have birthed global efforts to decolonize expertise and authority across multiple spheres of economic and educational activity. In February 2019, public health students at Harvard organized a conference on decolonizing global health. They wrote:
We want to ask reflexive and difficult questions. What does it mean to engage in this field without acknowledging and tackling the history of colonial plunder? What does it mean to not acknowledge the role of global capitalism in generating the unequal conditions that manifest as health and disease? How can we as practitioners of ‘global health’—a debatable term that either needs redefining or abandonment—learn, know, teach, and do based on the kind of society we want to see, not the one that we currently have? (Harvard Chan Student Committee for the Decolonization of Public Health 2019)
The approach to undergraduate global health education we have outlined above attempts to locate present-day work conducted in the name of “global health” in these historical, political, and economic structures. Toward that end and toward the development of a new generation of leaders, we encourage fellow educators, first, to call attention to the racialized hierarchies of expertise and technical assistance that are foundational to contemporary public health systems and practice; second, to replace the language of “helping” with the language of solidarity and partnership while remaining attentive to the power of purse strings to set agendas even in the face of good intentions; third, to highlight interventions, projects, and health promotion movements created by people outside hegemonic global health institutions; and finally, to turn a critical eye toward the ways that the language of global health persists in separating the world into victims and saviors and to guard against reproducing these categories.
We believe that teaching global health in the undergraduate liberal arts context requires that we recognize the unique opportunities afforded by this setting and step up to the very real responsibilities associated with preparing young people, whether for a summer of experiential learning or a lifetime of leadership in this field. A structural competency approach compels us to leverage the resources of the liberal arts toward the development of a critically engaged, self-aware, and justice-oriented undergraduate global health curriculum.
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Anna West is Assistant Professor and Director of Health Studies and Anne Montgomery is Visiting Assistant Professor of Health Studies—both at Haverford College.