Structural competency in global perspective.

This special issue aims to help fill two critical gaps in the growing literature as well as in practice. First, to bring together scholars and practitioners from around the world who develop, practice, review, and question structural competency with the aim of promoting a dialogue with related approaches, such as Latin American Social Medicine, Collective Health, and others, which have been key in diverse geographical and social settings. Second, to contribute to expanding structural competency beyond clinical medicine to include other health-related areas such as social work, global health, public health practice, epidemiological research, health policy, community organisation and beyond. This conceptual expansion is currently taking place in structural competency, and we hope that this volume will help to raise awareness and reinforce what is already happening. In sum, this collection of articles puts structural competency more rigorously and actively in conversation with different geographic, political, social, and professional contexts worldwide. We hope this conversation sparks further development in scholarly, political and community movements for social and health justice.

Criminology and identity: A theoretical review / Criminología e identidad: una revisión teórica / Criminologia e identidade: uma revisão teórica

This article is a literature review describing and analysing the main theoretical and empirical developments that have addressed the concept of identity and its role in crime based on criminology and other disciplines. The literature review was based on a search both in Spanish and English in the Web of Knowledge, Scopus, and Scielo databases. The exposition of theoretical proposals follows a chronological and disciplinary field order, including identity perspective, the sociology of deviance, developmental criminology, and several of the leading contemporary approaches. It highlights the dissemination and importance of identity perspective between the 1950s and 1970s and the subsequent criticism that it was reductionist, lacking theoretical support, and not in dialogue with other criminological proposals. Thereupon, emphasis is placed on the subsequent contributions and proposals, which demonstrate the consistency of the concept, as well as its versatility and articulation with different disciplinary approaches to the understanding of the criminal phenomenon. The conclusion highlights the richness of the concept, its projections, and the importance of its revitalisation.

Este artículo es una revisión bibliográfica en la que se describen y analizan los principales desarrollos tanto teóricos como empíricos que han abordado el concepto de identidad y su rol asociado a la delincuencia, desde la criminología y otras disciplinas. La revisión bibliográfica se basó en una búsqueda en español e inglés en las bases de datos Web of Knowledge, Scopus y Scielo. La exposición de propuestas teóricas sigue un orden cronológico y de campo disciplinar, incluyendo la perspectiva de la identidad, la sociología de la desviación, la criminología del desarrollo y algunos de los principales planteamientos contemporáneos. Se destaca la difusión e importancia que tuvo la perspectiva de la identidad entre los años cincuenta y setenta, y la posterior crítica que la señaló como reduccionista, carente de sustento teórico y poco dialogante con otras propuestas criminológicas. Luego se enfatiza en las contribuciones y propuestas posteriores, las que dan cuenta de la consistencia del concepto, así como de su versatilidad y articulación con distintas aproximaciones disciplinares abocadas a la comprensión del fenómeno delictivo. Se concluye destacando la riqueza del concepto, sus proyecciones y la importancia de su revitalización.

Este artigo é uma revisão bibliográfica que descreve e analisa os principais desenvolvimentos teóricos e empíricos que abordaram o conceito de identidade e seu papel associado ao crime, a partir da criminologia e de outras disciplinas. A revisão bibliográfica baseou-se em uma busca em espanhol e inglês nas bases de dados Web of Knowledge, Scopus e Scielo. A apresentação das propostas teóricas segue uma ordem cronológica e disciplinar de campo, incluindo a perspectiva identitária, a sociologia do desvio, a criminologia do desenvolvimento e algumas das principais abordagens contemporâneas. Destaca-se a difusão e importância que a perspectiva identitária teve entre as décadas de 1950 e 1970. E as críticas posteriores que a apontaram como reducionista, carente de respaldo teórico e pouco diálogo com outras propostas criminológicas. Em seguida, destacam-se as contribuições e propostas subsequentes, que dão conta da consistência do conceito, bem como da sua versatilidade e articulação com diferentes abordagens disciplinares destinadas à compreensão do fenómeno criminal. Conclui-se destacando a riqueza do conceito, suas projeções e a importância de sua revitalização.

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.

The Right to Health Care Viewed from the Indigenous Research Paradigm: Violations of the Rights of an Aymara Warmi in Chile's Tarapacá Region.

This paper reflects on the right to health care from the Indigenous research paradigm. We analyze the case of an Aymara wise warmi (woman) who died after the Chilean health care system failed to provide culturally appropriate care. In the wake of her death, our cooperative launched an interdisciplinary and collaborative research project in an effort to file an administrative complaint against the family health center that treated her. We explore the events surrounding her treatment and death, as well as the institutional written response. Our work elucidates the significant differences that exist between institutional and Indigenous perspectives on what constitutes a violation of the right to health care. We demonstrate that in order to establish the existence of such violations, Aymara people are compelled to develop evidence using a naturalistic scientific and legal framework that does not coincide with their ontology. Consequently, some events and violations are not legally recognized as culturally inappropriate health care unless they are viewed through an Indigenous lens. Finally, we reflect on the problem of evidence production, specifically regarding the right to health care. We argue that the fight for the right to health care can benefit from the Indigenous research paradigm-not only for the benefit of Indigenous people but also to provide culturally appropriate care to all people.

Beyond the classroom: The development of collective structural competency in pro-migrant activism.

Structural competency proposals have been developed as part of an effort to infuse clinical training with a structural focus. Framed in the context of medical education, the discussion on structural competency naturally emphasises the development of such competency in healthcare workers. In this article, we shift the focus to reflect on how the work of migrant community leaders may involve the development of structural competencies and what can be learned from this complementary perspective. We analysed the development of structural competency in an immigrant rights organisation in northern Chile. We conducted focus groups with migrant leaders and volunteers and used the tools proposed by the Structural Competency Working Group to facilitate dialogue. This allowed us to verify the development of structural competency and other collective competencies, including the capacity to create a protected space for circulating experiences and knowledge; coordinate a heterogeneous group of agents; have a socio-legal impact; and maintain autonomy concerning ideological production. This article introduces the concept of collective structural competency and reflects on the importance of expanding beyond the common medical-centred approach when considering structural competency.

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.

Indigenous Border Migrants and (Im)Mobility Policies in Chile in Times of COVID-19.

The commodification of healthcare and the structural violence towards the migrant population in the Chilean system materialize in a series of structural barriers to accessing healthcare. In the face of this structural vulnerability, cross-border health mobility is one of the primary resources of indigenous border migrants living in the Tarapacá region (Chile). This involves crossing the border of both people (specialists/patients) and objects (such as ritual supplies or biomedicines), which play a crucial role as, in many cases, it is the only way to satisfy their healthcare needs. The security-orientated geopolitics of border closure (Plan Frontera Segura) has been reinforced by immobility policies linked to the COVID-19 pandemic. While doing so leaves people without the fundamental resource of healthcare mobility or obliges them to cross the border via unauthorized crossings, exposing them to criminalization and abuse by different agents of violence (the military, people smugglers, etc.). In this paper, we will offer a description of these processes of (im)mobility, analyzing their conformation both by the current policies of the Chilean State and by the notorious deficiency in indigenous and migrant rights, denouncing the material impact they have on the health/illness/care process of indigenous migrants.

Ideological assumptions of Chile's international migrant healthcare policy: A critical discourse analysis.

In the current historical moment of rewriting the Chilean Constitution, there are new hopes for producing a different socio-legal, political-economic and public health order. The Chilean case holds important implications for global health practitioners, researchers and policy-makers because it clearly shows both the impacts of neoliberal processes on a worldwide scale and neoliberal policy responses. This article contributes to the field of global health policy critical analysis by offering scrutiny of Chile's international migrant healthcare policy from the perspective of its ideological assumptions. We apply Fairclough's analytical perspective to the Chilean migrant healthcare policy, identifying its components, argumentative premises and ideological assumptions that contribute to the reproduction of the processes of social determination. It allows us to identify bias mobilisation, exclusion, and subordinate inclusion processes that systematically lead to the omission of structural processes in the social determination of migrants' healthcare, contributing to their reproduction. We conclude by problematising the place of academia in said reproduction to the extent that the concepts and premises they use remain in the ideological territory of exclusion of the structural defined by the policy, disconnecting reflection and action in the health field from collective demands.

How Should Clinicians Express Solidarity With Asylum Seekers at the US-Mexico Border?

Migrants along the US-Mexico border have been subjected to transnational violence created by international policy, militaristic intervention, and multinational organizational administration of border operations. The COVID-19 pandemic compounded migrants' vulnerabilities and provoked several logistical and ethical problems for US-based clinicians and organizations. This commentary examines how the concept of transnational solidarity facilitates analysis of clinicians' and migrants' shared historical and structural vulnerabilities. This commentary also suggests how actions implemented by one organization in Tijuana, Mexico, could be scaled more broadly for care of migrants and asylum seekers in other transnational health care settings.

Los migrantes en la frontera entre EE. UU. y México han sufrido violencia transnacional por parte de la policía internacional, la intervención militar y la administración organizativa multinacional de las operaciones fronterizas. La pandemia de la COVID-19 agravó las vulnerabilidades de los migrantes y provocó varios problemas logísticos y éticos para los médicos y las organizaciones estadounidenses. Este comentario examina de qué manera el concepto de solidaridad transnacional facilita el análisis de los médicos y las vulnerabilidades históricas y estructurales compartidas de los migrantes. También, sugiere cómo las acciones implementadas por una organización en Tijuana, México, podrían aplicarse a mayor escala para la atención de los migrantes y solicitantes de asilo en otros entornos de atención médica transnacional.

Structural vulnerability: migration and health in social context.

Based on the authors' work in Latin America and Africa, this article describes and applies the concept 'structural vulnerability' to the challenges of clinical care and healthcare advocacy for migrants. This concept helps consider how specific social, economic and political hierarchies and policies produce and pattern poor health in two case studies: one at the USA-Mexico border and another in Djibouti. Migrants' and providers' various entanglements within inequitable and sometimes violent global migration systems can produce shared structural vulnerabilities that then differentially affect health and other outcomes. In response, we argue providers require specialised training and support; professional associations, healthcare institutions, universities and humanitarian organisations should work to end the criminalisation of medical and humanitarian assistance to migrants; migrants should help lead efforts to reform medical and humanitarian interventions; and alternative care models in Global South to address the structural vulnerabilities inherent to migration and asylum should be supported.

Perspectivas teóricas sobre salud y migración: determinantes sociales, transnacionalismo y vulnerabilidad estructural / Theoretical perspectives on health and migration: social determinants, transnationalism, and structural vulnerability

Resumen El artículo analiza críticamente las tres aproximaciones teóricas contemporáneas más importantes en el abordaje del binomio salud-migración: el enfoque de determinantes sociales de la Organización Mundial de la Salud; los estudios sobre transnacionalismo y salud; y las propuestas sobre vulnerabilidad estructural. Se exponen las ideas centrales que les caracterizan y se presentan las principales críticas realizadas. Dado que la mayor parte de la literatura actual está siendo publicada en inglés, el artículo acerca de manera sintética algunas de las principales contribuciones en la materia al público hispanohablante, siendo el primer trabajo de este tipo que incluye la aproximación de la vulnerabilidad estructural. El análisis se apoyó en el software CAQDAS Nvivo, utilizando análisis de contenido sumariante, estructurante y explicativo. El trabajo enfatiza la importancia de los procesos de determinación estructural de la salud de los migrantes, y concluye abogando por un análisis de las convenciones científicas presentes en las perspectivas teóricas, en tanto estas tienen un impacto concreto en la salud de los migrantes, como fundamentos de políticas y como materia prima para el sentido común.

Abstract This article critically analyzes the three major contemporary theoretical approaches in addressing health and migration: the social determinants of health approach of the World Health Organization; studies on transnationalism and health; and current proposals on structural vulnerability. To this end, the core ideas that characterize each of these approaches and the main criticisms made are presented. Given that most of the current literature is being published in English, this article summarizes some of the main contributions in the field for the Spanish-speaking public, constituting the first work of this type to include the structural vulnerability approach. The analysis was carried out with CAQDAS Nvivo, using summarizing, structuring, and explanatory content analysis. The article emphasizes the importance of the processes of structural determination of the health of migrants and concludes by advocating an analysis of the scientific conventions present in the theoretical perspectives, insofar as these have a concrete impact on the health of migrants, as policy's foundations and as raw material for common sense.

La subordinación ideológica del saber médico andino en la salud intercultural chilena / The ideological subordination of the Andean Medical Knowledge in Chilean Intercultural Health

Existen pocos estudios que aborden los procesos ideológicos presentes en las relaciones interculturales propiciadas por las iniciativas de Salud de los Pueblos Indígenas en Chile. Nuestro objetivo es mostrar cómo los elementos ideológicos del Saber Biomédico contribuyen a la subordinación del Saber Andino al interior de dichos programas. Para esto, expondremos material etnográfico producido entre 2011 y 2012 en la comunidad de Camiña, Tarapacá. Posicionados desde la Antropología Médica Crítica, analizamos la ideología biomédica sobre el Saber Andino, así como las propuestas para la interculturalidad que surgen desde el personal biomédico. Concluimos reflexionando cómo la negación del carácter ideológico de la racionalidad biomédica, refuerza la subordinación del Saber Andino, produciendo un efecto opuesto al mentado en la política pública.

There are few studies that address the ideological processes present in the intercultural relations fostered by the Indigenous Peoples Health initiatives in Chile. Our objective is to show how the ideological elements of Biomedical Knowledge contribute to the subordination of Andean Knowledge within these programs. For this, we will exhibit ethnographic material produced between 2011 and 2012 in the community of Camiña, Tarapacá. Positioned from the Critical Medical Anthropology, we analyze the biomedical ideology on the Andean Knowledge, as well as the proposals for the interculturality that arise from the biomedical personnel. We conclude by reflecting on how the denial of the ideological character of biomedical rationality reinforces the subordination of Andean Knowledge, producing an adverse effect on public policy.

El imaginario de la horizontalidad como instrumento de subordinación: la Política de Salud pueblos indígenas en el multiculturalismo neoliberal chileno / The imaginary of horizontality as an instrument of subordination: the indigenous' peoples health policy in Chile's neoliberal multiculturalism

Resumen El artículo desarrolla un análisis documental de la Política de Salud Pueblos Indígenas chilena desde la Antropología Médica Crítica. Entendiendo las políticas públicas como producciones ideológicas, la contextualiza en la apuesta gubernamental del "Multiculturalismo neoliberal", analizando el sentido que en ese marco tienen los ejes de interculturalidad, equidad y participación, mostrando el carácter socioculturalista y voluntarista de los diagnósticos y abordajes que la constituyen. Desde un análisis de relaciones de hegemonía/subalternidad, muestra como la ahistoricidad que la caracteriza permite la producción de un imaginario de la horizontalidad en contextos de asimetría de poder, cumpliendo la función ideológica de sostener a la salud intercultural como respuesta ante el problema de la inequidad en salud, opacando la participación que esta política tiene en el proceso de producción de la misma inequidad. Se concluye interrogando la pertinencia de una política construida desde otros supuestos ideológicos.

Abstract This paper develops an analysis of documentary sources of chilean's Public Health Policy of Indigenous Peoples from a critical medical anthropology standpoint. Understanding public policy as ideological productions, it analyses the axis of interculturality, equity and participation in the context of Chile's governmental "Neoliberal multiculturalism", showing the socioculturalism and voluntarism that guide their diagnoses and actions. From an analysis of hegemony/subalternity relationships, it shows how de-historization allows the production of horizontality imaginary in contexts of power asymmetry, fulfilling the ideological function to support intercultural health as an answer to the problem of health inequity, darkening the participation that this policy has in the process of the same inequity's production. In the end, we conclude by asking the significance of a policy constructed from other ideological assumptions.

Lo moreno es bello. Componentes identitarios de las mujeres jóvenes evangélicas aymaras / Brown is beautiful. Identity components of young evangelical Christian Aymara women / O escuro é bonito. Componentes identitários das mulheres jovens evangélicas aymaras

En este artículo de investigación científica son descritas las concepciones sobre identidad cultural que expresan las jóvenes evangélicas aymaras de la región de Tarapacá en Chile, por medio de las cuales se enfrenta el vacío en el conocimiento sobre los procesos identitarios en poblaciones de jóvenes pentecostales aymaras, que incluyen sistemáticamente distinciones de género. El material forma parte de un estudio mayor que incluyó 25 entrevistas en profundidad a hombres y mujeres aymaras de sectores rurales y urbanos, entre enero y septiembre del 2013. Serán consideradas las entrevistas correspondientes a 8 jóvenes evangélicas estudiantes universitarias de entre 18 y 29 años de edad y se resaltarán tres componentes identitarios significativos: su relación con la masculinidad, la lengua como recurso de identificación, y el territorio como referente identitario. Por último, se concluirá analizando la importancia de la reflexividad sobre los propios supuestos en investigación como factores que invisibilizan los procesos de ciertos grupos sociales.

In this article the authors describe the conceptions of cultural identity that are expressed by young evangelical Christian Aymara women from the region of Tarapacá in Chile. There is a gap in the scientific knowledge regarding the identity processes that occur in the Pentecostal Aymara population, including systematic gender distinctions. The material is part of a major study and is based in 25 in-depth interviews with members of the Aymara communities that included men and women from both rural and urban sectors between January and September 2013. The study uses data from interviews with 8 evangelical university students (aged between 18 and 29 years). Three results are highlighted by the authors: their relation with masculinity, language as an identification resource and territory as a modality of identity. Finally, the article analyzes the importance of reflexivity about the researcher's own assumptions in investigation such as factors that obscure the processes of certain social groups.

Neste artigo são descritas as concepções da identidade cultural que expressam as jovens evangélicas Aimarás da região de Tarapacá no Chile, por meio das quais são enfrentados o vácuo no conhecimento sobre os processos de identidade em populações de jovens pentecostais aymaras, que sistematicamente incluem distinções de género. O material faz parte de um estudo maior, que incluiu 25 entrevistas em profundidade com homens e mulheres aimarás em áreas rurais e urbanas, entre Janeiro e Setembro de 2013. Serão consideradas as entrevistas correspondentes a 8 jovens evangélicas, estudantes universitárias entre 18 e 29 anos idade e destacaram-se tr componentes significativos de identidade: a sua relação com a masculinidade, a linguagem como meio de identificação e o território como uma referéncia de identidade. Finalmente, conclui-se, discutindo a importã¢ncia da reflexividade sobre as próprias premissas da investigação como factores que fazem invisíveis os processos de determinados grupos sociais.