Structural Competency curriculum aims spotlight on immigration

Student facilitators of the Structural Competency curriculum

November 15, 2017

OHSU School of Medicine students confronted the intersection of immigration and health Nov. 10 with a pair of lectures and a subsequent classroom discussion about the hurdles faced by Mexican migrant farmworkers in the U.S.

The lectures, "Health and the Migrant Farmworker" and "Fresh Fruit, Broken Bodies," were organized by second-year medical students, who lead the design and teaching of courses in Structural Competency, a relatively new method of teaching about the ways that social, economic, legal and cultural structures impact health. Each class in this fall semester course explores issues framed by these structures – such as institutional racism, gender, trauma, substance abuse and racism – and how the issues affect patient care. The course is required for all first-year medical students.

The curricula for each session is developed by a small team of second-year student facilitators, with teams rotating by theme. "We hope that structural competency teaches students that good intentions are not enough when it comes to being a good doctor," said Brett Lewis, a student in the M.D./M.P.H. program, and one of the facilitators for the immigration event. "By being able to recognize structures that impact the ways in which we view and treat our patients, we hope to can identify opportunities for solidarity with our patients and begin to address these root issues head on."

The personal becomes political

Jaime Arredondo, secretary-treasurer of Pineros y Campesinos Unidos del Noroeste (PCUN), kicked off the lectures by sharing his family's experience, framed by his father's arrival in the U.S. and then their lives in Woodburn, Ore., where they settled.

The political climate of the late 1970s through early 1980s was similar to that of today, with regard to immigration and immigrant communities. Workers faced—and continue to encounter—grueling conditions without many legal protections or recourse. PCUN was founded to inform community members about their rights and help advocate, on a larger scale, for improvements in living and working conditions.

And the work continues: even today, within a mile of the Woodburn outlet mall along I-5, there are labor camps where workers live without insulation or indoor plumbing.

Conversely, the extent of contributions made by farmworkers are hard to fully grasp. The agricultural workforce is critical to horticulture and food processing, ensuring food security for millions. Reforestation crews rebuild our ecosystems after wildfires, carrying bundles of trees up mountains for planting. Farmworkers also tend vineyards and hop farms. As Arredondo put it, "Thank a farmworker if you go have a beer."

Arredondo described the plight of migrant workers in America:

  • Life expectancy is 49, compared to the average Oregonian, which is 79.5 years.
  • Approximately 75 percent of migrant farmworkers have no access to health care.
  • 44 percent are food insecure; 14 percent go hungry.
  • With an average annual income of $16,000, families rely on inexpensive, low-nutrition foods that lead to diabetes, obesity and associated health problems.

The political gets personal

Seth Holmes, M.D., Ph.D., shared his perspective as a cultural and medical anthropologist and physician. In researching for his book Fresh Fruit, Broken Bodies, he spent more than a year living and working with undocumented indigenous Mexicans in the U.S. and Mexico. He observed the hierarchy of ethnicity and citizenship status, and saw the anxieties and privileges at each level. This view of "social Darwinism" at play provided context for the naturalizing of health inequities and outcomes among agricultural workers.

There are several explanations for these structural inequities—language barriers, access to clinics, long work hours with no breaks or sick time—but as Dr. Holmes summed it up, "it's just racism."

What does this background mean for a lecture hall full of medical students? Students attend the Structural Competency lectures on immigration

Dr. Holmes hearkened back to philosopher Michel Foucault and the "clinical gaze." Rather than listening to patients and asking "What's wrong?" physicians started asking "Where does it hurt?" In a push for efficiency, Dr. Holmes cautioned about losing our sense of what health is and where it comes from, and a tendency to blame the patient's body, genetics or behavior. This symbolic violence is the normalization and naturalization that justifies body and health inequities, along racialized lines.

Breaking it down, building it up

Both Arredondo and Dr. Holmes conclude that the best hope for the future is education. The children of agricultural workers are graduating from college and becoming leaders in their communities, and future clinicians are learning "structural humility" in how they interact with their patients.

Following Friday's lectures, students divided into small groups to discuss structures that impact populations and health care. They engaged in activities and conversations that sought to understand the perspectives of underserved patients, as well as overscheduled clinicians.

If I had this patient, what would I do differently?

Which statements in these medical history notes are making assumptions that show bias?

What structures are influencing me?

How can I effectively provide care for patients dealing with structural inequities?

Tajwar Taher, a first-year medical student, said the small-group discussion helped him to realize that recommendations and guidelines given to physicians come from a pedestal of privilege, leading to a homogenous approach that fails to address the needs of patients.

"When I'm a physician, I'll be challenged to adapt my treatments and recommendations for patients based on their social circumstances," Mr. Taher said. "I am extremely pleased that structural competency is part of our curriculum. Our patients will come to us with the hopes of leading a healthy life; if we're aware those lives depend on their social environments as much as the hearts beating within them, we'll make good on those hopes."