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

ABSTRACTStructural 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.

Empowering communities through experiential learning: the 'Enhance' program in Leadership and Social Medicine.

INTRODUCTION: Social determinants of health cause disparities in health and life expectancy in the UK1, especially in rural populations. Communities must be empowered to control their health2, alongside clinicians being more generalist and holistic. Health Education East Midlands is pioneering this approach, creating the 'Enhance' program. From August 2022, up to 12 Internal Medicine Trainees (IMT) will start the 'Enhance' program. They will spend 1 day per week learning about social inequalities, advocacy, and public health, before undertaking experiential learning with a community partner, working together to create and implement a Quality Improvement (QI) project. This will integrate trainees into communities, and help communities utilise assets to create sustainable changes. This longitudinal program will span over all 3 years of IMT. METHODS: After conducting a detailed literature search into experiential learning and service learning programs in medical education, virtual interviews were held with researchers worldwide to discuss how they created, implemented, and evaluated similar projects. The curriculum was created using Health Education England's 'Enhance' handbook, the IMT curriculum, and relevant literature. The teaching program was created with a Public Health specialist. RESULTS: The program commences in August 2022. Evaluation will commence thereafter. DISCUSSION: This will be the first experiential learning program of this scale in UK Postgraduate medical education, with future expansion focusing specifically on rural communities. Afterwards, trainees will understand the social determinants of health, health policy creation, medical advocacy, leadership, and research including asset-based assessments and QI. Trainees will be more holistic and generalist, working with and empowering their local communities. Future work will evaluate the program after commencement.References1 Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot Review ten years on. London: Institute of Health Equity, 2020. Available at https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on2 Hixon AL, Yamada S, Farmer PE, Maskarinec, GG. Social justice: the heart of medical education. Social Medicine 2013; 3(7): 161-168. Available at https://www.researchgate.net/publication/258353708_Social_Justice_The_Heart_of_Medical_Education.

Thinking with and Against the Social Determinants of Health: The Latin American Social Medicine (Collective Health) Critique from Jaime Breilh.

The concept of the social determinants of health has become increasingly accepted and mainstream in anglophone public health over the past three decades. Moreover, it has been widely adopted into diverse geographic, sociocultural, and linguistic contexts. By recognizing the role of social conditions in influencing health inequalities, the concept challenges narrow behavioral and reductive biological understandings of health. Despite this, scholars and activists have critiqued the concept of the social determinants of health for being incomplete and even misrepresenting the true nature of health inequities. Arguably, these critiques have been most thoroughly developed among those working in the Latin American social medicine and collective health traditions who formulated the "social determination of health" paradigm and the concept of interculturality decades prior to the advent of the social determinants of health. We draw on Jaime Breilh's main works, with a focus on the recently published book, Critical Epidemiology and the People's Health, to (1) provide a broad overview of the social determination of health paradigm and its approach to interculturality and (2) clarify how these ideas and the broader collective health movement challenge assumptions within the social determinants of health concept.

To what extent are midwives adapting antenatal information for pregnant women with intellectual disabilities? A survey of NHS trusts in England.

OBJECTIVES: To identify the existing antenatal information provision practices for pregnant women with intellectual disabilities in England. To identify how practices between and within local supervising authorities differed, and if midwives were adapting standard antenatal information for pregnant women with intellectual disabilities, including examples of accessible information being used. STUDY DESIGN: Cross-sectional survey. METHODS: All contact supervisors of midwives from acute trusts with maternity services were accessed via the local supervisor of midwives officers' databases and sent a questionnaire. Quantitative data were collated. Associations between trust size, geographical location, antenatal provision and National Institute for Health and Care Excellence guidelines alongside National policy were examined using Fischer's exact test of association. RESULTS: Contact supervisors of midwives returned a questionnaire on behalf of their trust (74, 53%). The majority worked in maternity units with more than 4000 births a year (50, 66%). Few trusts had a specialist or lead midwife in post for pregnant women with intellectual disabilities (17, 22.9%) but over half (39, 52.7%) reported that their trust had a specialist learning disability nurse in post. Only 28.3% reported availability of post registration training and even fewer (8, 10.8%) had access to written protocols. Less than half reported extra time being offered at the booking (29, 39.1%) or routine antenatal appointments (30, 40.5%). Less than a quarter (17, 22.9%) reported that their trust had routine antenatal written information available in accessible formats. CONCLUSION: Reasonable adjustments to standard antenatal information for pregnant women with intellectual disabilities were not common practice. Most trusts did not have local guidelines in place or offer midwives post registration education to help support them in this requirement.

La medicina social-salud colectiva latinoamericanas: una visión integradora frente a la salud pública tradicional / Latin-American Social Medicine/Public Health: An Integrative Vision Facing Traditional Public Health

Introducción: la salud pública, cuyo abordaje conceptual es el funcionalismo, mantiene una crisis histórica para resolver los problemas de atención a la enfermedad y generación de salud, tanto de individuos como de colectivos. Una explicación es que su base epistemológica es restrictiva y los propios recursos existentes en los sistemas de salud no garantizan la salud ni contribuyen integralmente a mejorar la calidad de vida de las poblaciones. Desarrollo: por su parte, la corriente de pensamiento de la medicina social y salud colectiva (ms/sc) latinoamericana amplió este horizonte debatiendo sobre el sentido epistemológico del objeto salud como un campo disciplinar complejo donde los saberes y prácticas son abordados desde distintos paradigmas o perspectivas epistémicas. La ms/sc resignifica la noción del proceso salud-enfermedad, nutriéndose de la incorporación de diferentes procesos. A través de una aproximación conceptual, este artículo busca señalar y destacar de manera sucinta parte de la construcción de esta corriente de pensamiento en relación con tres procesos: la consideración epistemológica del objeto salud, la relación entre las ciencias sociales y la salud, y la crítica al modelo preventivista y a la epidemiología convencional. Conclusiones: los anteriores aspectos posibilitan la vigencia de la ms/sc como corriente de pensamiento y hacen evidente su contribución para interpretar las afectaciones del proceso salud-enfermedad en contextos adversos, que son producto de la mercantilización de la salud y de la crisis del Estado.

Making the most of open windows: establishing health in all policies in South Australia.

Significant improvements in population health are likely to arise when the social determinants ofhealth are addressed. This creates a challenge for health systems, as the policy levers to influence the determinants largely lie outside of their direct control. Health agencies have been attempting to develop responses that affect these policy levers with mixed success. Success often requires particular conditions or "windows of opportunity" to be present before even small systemic change can be made. The government of South Australia has developed a practical, policy-oriented response to address the determinants of health--Health in All Policies--and has been successfully working across government for the past five years, using a policy learning process to implement this approach. This article will focus on how the South Australian Health in All Policies initiative started and the conditions that enabled South Australia to establish a centralized governance structure, harness a group of cross-sector policy entrepreneurs, and conduct health lens projects across a range of policy issues. The authors will comment on the nature of these conditions and their relevance for other governments struggling to reduce the burden of chronic disease and growing health budgets by addressing the social determinants of health.

Curanderos, contras y culebras / Quacks, cons and snakes

Estamos en pleno auge de una gigantesca sociedad industrial globalizada, que es manejada por múltiples organismos, muchos de los cuales solo conocemos por siglas: FMI, OCDE, OTAN, Los 20, OMC, Los 7… Es también una época en que los estándares determinan el procedimiento para conseguir una cita médica que, por otra parte, se presta cuando se puede con recursos técnicos que ni soñábamos hace medio siglo.

We are at the height of a giant globalized industrial society, which is managed by multiple agencies, many of whom we know only by initials: IMF , OECD , NATO, The 20 , WTO 7 ... It is also a time when standards determine the procedure for getting a doctor's appointment , on the other hand, lends -when technical resources can- not dreamed half a century...

Evaluation of the project P.A.T.H.S. based on students' weekly diaries: findings from eight datasets.

This paper aims to investigate the effectiveness of the Tier 1 Program of the Project P.A.T.H.S. (positive adolescent training through holistic social programmes) based on eight datasets collected between 2005 and 2009. A total of 1,138 students who participated in the program were randomly invited (from the whole grade or in some classes) to write a piece of journal in the form of a weekly diary in order to reveal their perceptions and feelings regarding the program and the perceived benefits of the program. Based on an integration of findings from different databases, results showed that the respondents generally (1) had positive views on the program, (2) had positive views on the instructors, and (3) perceived that they had acquired competencies at the societal, school, familial, interpersonal, and personal levels after joining the program. Acknowledging the limitations of diaries, the present qualitative findings provide support for the effectiveness of the Tier 1 Program of the Project P.A.T.H.S. in Hong Kong.

Evaluation of a positive youth development program based on the repertory grid test.

The repertory grid test, based on personal construct psychology, was used to evaluate the effectiveness of Project P.A.T.H.S. (Positive Adolescent Training through Holistic Social Programmes) in Hong Kong. One hundred and four program participants (n = 104) were randomly invited to complete a repertory grid based on personal construct theory in order to provide both quantitative and qualitative data for measuring self-identity changes after joining the program. Findings generally showed that the participants perceived that they understood themselves better and had stronger resilience after joining the program. Participants also saw themselves as closer to their ideal selves and other positive role figures (but farther away from a loser) after joining the program. This study provides additional support for the effectiveness of the Tier 1 Program of Project P.A.T.H.S. in the Chinese context. This study also shows that the repertory grid test is a useful evaluation method to measure self-identity changes in participants in positive youth development programs.

A personal view on systems medicine and the emergence of proactive P4 medicine: predictive, preventive, personalized and participatory.

Systems biology and the digital revolution are together transforming healthcare to a proactive P4 medicine that is predictive, preventive, personalized and participatory. Systems biology - holistic, global and integrative in approach - has given rise to systems medicine, a systems approach to health and disease. Systems medicine promises to (1) provide deep insights into disease mechanisms, (2) make blood a diagnostic window for viewing health and disease for the individual, (3) stratify complex diseases into their distinct subtypes for a impedance match against proper drugs, (4) provide new approaches to drug target discovery and (5) generate metrics for assessing wellness. P4 medicine, the clinical face of systems medicine, has two major objectives: to quantify wellness and to demystify disease. Patients and consumers will be a major driver in the realization of P4 medicine through their participation in medically oriented social networks directed at improving their own healthcare. P4 medicine has striking implications for society - including the ability to turn around the ever-escalating costs of healthcare. The challenge in bringing P4 medicine to patients and consumers is twofold: first, inventing the strategies and technologies that will enable P4 medicine and second, dealing with the impact of P4 medicine on society - including key ethical, social, legal, regulatory, and economic issues. Managing the societal problems will pose the most significant challenges. Strategic partnerships of a variety of types will be necessary to bring P4 medicine to patients.

[Social medicine in medical faculties: realisation of the topic in the specialty "social medicine, occupational health"]. / Sozialmedizin an medizinischen Fakultäten: Realisierung des Teilbereichs im Fach "Sozialmedizin, Arbeitsmedizin".

PURPOSE OF THE STUDY: The 9 (th) Revision of German Medical Licensing Regulations for Physicians has come into effect on October 1 (st) 2003. Social medicine was separated into the fields ""occupational health, social medicine" and the various cross-sectional modules: epidemiology, biometry, medical computer science; health economics, health-care system, public health; prevention, health promotion; rehabilitation, physical medicine, naturopathic treatment. This paper studies the realisation of teaching in the field social medicine at German medical faculties. METHODS: The survey was conducted in collaboration with the German Association for Social Medicine and Prevention (DGSMP). A survey was conducted at 38 institutes of 36 German medical faculties. The written questionnaire contained mostly selection items in which chances and barriers of the field were queried with supply items. Information about time scale, general conditions and resources was aked for. On the basis of the guidelines of the DGSMP, the topics to be taught were evaluated concerning their relevance and integration into education. RESULTS: The response rate was 68% (n=26). Social insurance, basic principles, responsibility in the Social Security Code and the different providers were judged as the most important topics. There was a strong demand for lecturing material. 82% (n=18) of the faculties wished to have specific material, for example e-learning, examples, lesson plans, curricula and also textbooks. 91% (n=19) of the faculties requested an exchange of information between the faculties concerning educational contents, motivation of students and e-learning. DISCUSSION: The realisation of teaching is different between the faculties concerning the number of hours, teaching methods and number of students per year. The motivation of the students is one of the problems, but also the lack of acceptance within the clinic. Specific resources and exchange between the faculties are necessary concerning e-learning, which is offered at only few faculties so far, but interest for a more intensive usage exists. Potentials of social medicine are the promotion of awareness among the students and the "identification of basics for medical acts in the social security system". Social medicine offers the possibility to connect the theoretical institutes with the clinic.

Between clinical medicine and the laboratory: medical research funding in France from 1945 to the present.

By focusing on funding methods, this paper considers the way in which medical research eventually led to the science-based medicine that is prevalent in France today. This process seems to have taken place in three stages during the second half of the twentieth century. In the 1940s and 1950s, two major events occurred. The first was the creation of a national health insurance fund in France, which opened up new reasons for, and ways of, funding medical research. The second was the development of antibiotics, which triggered a revival of clinical medicine. In the 1960s and 1970s, a proactive government science policy allowed the life sciences and medical research to come together in the wake of a burgeoning new science: molecular biology. Thus, in 1964, the creation of the National Health and Medical Research Institute (Institut national de la santé et de la recherche médicale or INSERM), destined to "molecularize" medical research, was seen as the fulfillment of the government's ambitious research policy. Today, with medicine irreversibly embedded in scientific and technical rationality, health has become a major issue in modern societies. This paper therefore touches on some of the key features of biomedical research, including the revival of funding systems for clinical research and the development of a system of research grants that was made possible by patient organizations and the creation of new funding agencies.

La experiencia de medicina preventiva integrada a la clínica: Hospital San Francisco de Borja 1963-1973 / Teaching preventive medicine in a clinical setting: San Francisco de Borja Hospital 1963-1973

Este trabajo intenta comprender la experiencia de medicina preventiva integrada a las clínicas, realizadas entre los años 1963 y 1973, en el Hospital San Francisco de Borja. El análisis busca conocer sus contenidos, su marco teórico, sus participantes, sus antecedentes y algunas de sus posibles implicancias para la salud pública actual. Como introducción al estudio mismo, realizó una revisión parcial de los vínculos entre historia y salud pública en el contexto americano y un recuento de las búsquedas historiográficas relevadas por el “giro lingüístico” y las tensiones entre memoria e historia. De esta revisión y recuento se da cuenta en otro artículo.

This paper attempts to understand the experience of integrated medicine clinics, between the years 1963 and 1973 in San Francisco de Borja Hospital. The analysis seeks to know its contents, its theoretical framework, its participants, their background and some of its possible implications for public health today. As an introduction to the study it conducted a partial review of the links between history and public health in the American context and an overview on historiographic controversy caused by “linguistic turn” and the tensions between memory and history. This review is the subject matter of another paper.

Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde / Social medicalization and alternative and complementary medicine: the pluralization of health services in the Brazilian Unified Health System / Medicalización social y medicina alternativa y complementaria: pluralización terapéutica del Sistema Único de Salud

A medicalização social transforma a cultura, diminui o manejo autônomo de parte dos problemas de saúde e gera excessiva demanda ao Sistema Único de Saúde. Uma alternativa à medicalização social no âmbito da atenção à saúde é a pluralização terapêutica das instituições de saúde, ou seja, a valorização e o oferecimento de práticas e medicinas alternativas e complementares. O objetivo do artigo foi analisar potencialidades e dificuldades de práticas e medicinas alternativas e complementares a partir de experiências clínico-institucionais e da literatura especializada. Conclui-se que tal estratégia tem um limitado potencial "desmedicalizante" e deve ser assumida pelo Sistema Único de Saúde. Ressalta-se ainda que devem ser observadas a hegemonia político-epistemológica da Biociência e a disputa mercadológica atual no campo da saúde, cuja tendência é transformar qualquer saber/prática estruturado do processo saúde-doença em mercadorias ou procedimentos a serem consumidos, reforçando a heteronomia e a medicalização.

Evaluation of Project P.A.T.H.S. In Hong Kong: triangulation of findings based on different evaluation strategies.

There are different adolescent developmental issues in Hong Kong, such as mental health problems, abuse of psychotropic substances, adolescent suicide, school violence, and drop in family solidarity, that deserve the attention of helping professionals[1]. With reference to these problems, primary prevention programs that target specific adolescent developmental problems and positive youth development programs are called for. Furthermore, attempts to identify the "at-risk" adolescents at an earlier stage are important. However, research findings show that there are very few systematic and multiyear positive youth development programs in Hong Kong. Even if such programs exist, they commonly deal with isolated problems and issues in adolescent development (i.e., deficits-oriented programs) and they are relatively short term in nature. In addition, systematic and long-term evaluation of the available programs does not exist[2].