Structural Competency in Mental Health and Medicine Helena Hansen • Jonathan M. Metzl Editors Structural Competency in Mental Health and Medicine A Case-Based Approach to Treating the Social Determinants of Health Editors Helena Hansen Jonathan M. Metzl New York University Center for Medicine, Health, and Society New York, NY Vanderbilt University USA Nashville, TN USA ISBN 978-3-030-10524-2 ISBN 978-3-030-10525-9 (eBook) https://doi.org/10.1007/978-3-030-10525-9 Library of Congress Control Number: 2019935847 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword: The Promise of Structural Competency In 1966, Dr. Martin Luther King, Jr., singled out one form of inequality as especially egregious: “Of all the forms of inequality, injustice in health is the most shocking and inhuman.”1 Health disparities are not just a biological reality; they are a form of social inequality because they are structured according to unjust power arrange- ments. Numerous studies have established that the best predictor of health is an individual’s position in the social order.2 Poor health is a function of occupying a disadvantaged position in our society, while having better health is a benefit of being socially privileged. Similarly, people of color in the United States experience greater rates of morbidity and mortality than whites.3 Dr. King’s interpretation of health disparities as a key form of injustice also highlights how biological and cul- tural explanations for racial gaps in health help to support an unjust social order. For centuries, dominant approaches to medicine and public health in the United States have woefully mistreated health inequities. Doctors and clinicians have not only ignored structural causes of health disparities; they have also helped to per- petuate unequal social structures. By attributing gaps in health to the innate or cul- tural traits of socially disadvantaged groups, medical professionals have obscured the very existence of political oppression. The racial concept of disease – that peo- ple of different races have different diseases and suffer from common diseases dif- ferently – has served since the slavery era to explain away the toll of oppression on African Americans and even to justify subordinating them for medical reasons. Dr. Samuel Cartwright, a well-known expert on “Negro medicine” before the Civil War, claimed that because black people had lower lung capacity than whites, forced labor 1 Dr. Martin Luther King on Health Care Injustice, Physicians for A Nat’l Health Program (Oct. 14, 2014), http://www.pnhp.org/news/2014/october/dr-martin-luther-king-on-health-care-injustice 2 See Donald A. Barr, Health Disparities in the United States: Social Class, Race, Ethnicity, and Health (2008); Nancy E. Adler & David H. Rehkopf, U.S. Disparities in Health: Descriptions, Causes, and Mechanisms, 29 Ann. Rev. Pub. Health 235 (2008). 3 See Nat’l Ctr. for Health Statistics, Ctr. for Disease Control and Prevention, Health, United States 2015: With Special Feature on Racial & Ethnic Health Disparities 37–38, 100–01 (May 2016), http://www.cdc.gov/nchs/data/hus/hus15.pdf; Robert S. Levine, James E. Foster & Robert E. Fullilove, Black-White Inequalities in Mortality and Life Expectancy, 1933–1999: Implications for Health People 2010, 116 Pub. Health Rep. 474, 480 (2001); David R. Williams, Miles To Go Before We Sleep: Racial Inequities in Health, 53 J. Health & Soc. Behav. 279, 280 (2012). v vi Foreword: The Promise of Structural Competency was good for them.4 Locating blacks’ subordinated status in biological susceptibil- ity later legitimized the white supremacist regime inherited from slavery. The explanation for health disparities as caused by innate distinctions in disease diverts attention and resources from ending health disparities’ structural causes and perpetuates the false belief that social inequality stems from biological differences. Using biological terms to define social inequities makes them seem natural – the result of inherent group differences that can’t be changed instead of unjust societal structures that must be dismantled. Attributing health disparities to cultural differ- ences in health behaviors makes them seem the fault of the very groups who face the greatest structural barriers to good health and well being. These ways of thinking serve as a powerful barrier to support for structural changes needed to create a more equal society in which everyone would be healthier. We have long known that health inequities are caused by the structural determi- nants of health. A growing field of empirical research demonstrates that racism negatively affects the health of African Americans through a variety of pathways.5 Scientists are now uncovering the biological pathways that translate inequities in wealth, employment, health care, housing, incarceration, and education, along with experiences of stigma and discrimination, into disparate health outcomes. Institutionalized racism in these systems restricts access to resources required for health and well being. Numerous studies have identified racially segregated housing as a key contributor to health disparities because it concentrates poverty and mini- mizes resources needed for good health in predominantly black neighborhoods.6 As a group of health researchers recently summarized, racial residential segregation harms health through multiple pathways, including “the high concentration of dilapidated housing in neighbourhoods that people of color reside in, the substan- dard quality of the social and built environment, exposure to pollutants and toxins, limited opportunities for high-quality education and decent employment, and restricted access to health care.”7 In addition, the psychosocial stressors related to living in a high-poverty neighborhood are intensified by stress stemming from racial discrimination in health care, schools, employment, foster care, prisons, and polic- ing that prevails in these same areas.8 By geographically concentrating racism and 4 Lundy Braun, Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics 28 (2014). 5 See, e.g., Elizabeth Brondolo, Linda C. Gallo & Hector F. Myers, Race, Racism and Health: Disparities, Mechanisms, and Interventions, 32 J. Behav. Med. 1 (2009); David R. Williams & Selina A. Mohammed, Racism and Health I: Pathways and Scientific Evidence, 57 Am. Behav. Sci. 1152 (2013); Zinzi D. Bailey et al., Structural Racism and Health Inequities in the USA: Evidence and Interventions, 389 The Lancet 1453, 1456–58 (2017). 6 See David R. Williams & Chiquita Collins, Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health, 116 Pub. Health Rep. 404, 410–11 (2001); Williams & Muhammed, at 1158–59. 7 Bailey et al., at 1456; Williams & Muhammed, at 1159. 8 See Camara Jules P. Harrell et al., Multiple Pathways Linking Racism to Health Outcomes, 8 Du Bois Rev. 143, 153 (2011); Nancy Krieger, Discrimination and Health Inequities, 44 Int’l J. Health Servs. 643, 652–54 (2014); Williams & Mohammed, at 1163–64. Foreword: The Promise of Structural Competency vii poverty, residential segregation creates neighborhood environments for black resi- dents that are extraordinarily destructive to their health. Yet the biological and cultural accounts of racial and other health disparities continue to shape medical ideas and practices today.9 Medical education in the United States typically perpetuates biological concepts of race, the racial concept of disease, and stereotypes about racial differences that contribute to inferior treatment of black patients. Treating patients by race is still a foundation of medical educa- tion: students are routinely taught to identify a patient’s race and to use it as a proxy for more important clinical factors. At the same time, public health and biomedical researchers increasingly focus on genetic differences to explain health disparities. Rather than grapple with racist ideas embedded in the curriculum, medical schools have sought to address physician bias by requiring students, interns, and residents to be trained in “cultural competency” to better understand