Toward an Integrated Framework in Health and Human Rights Education: Transformative Pedagogies in Social Medicine, Collective Health, and Structural Competency.

Global health equity is at a historically tenuous nexus complicated by economic inequality, climate change, mass migration, racialized violence, and global pandemics. Social medicine, collective health, and structural competency are interdisciplinary fields with their own histories and fragmentary implementation in health equity movements situated both locally and globally. In this paper, we review these three fields' historical backgrounds, theoretical underpinnings, and contemporary contributions to global health equity. We believe that intentional dialogue between these fields could promote a generative discourse rooted in a shared understanding of their historical antecedents and theoretical frameworks. We also propose pedagogical tools grounded within our own critical and transformative pedagogies that offer the prospect of bringing these traditions into greater dialogue for the purpose of actualizing the human right to health.

Rethinking global health from south and north: A social medicine approach to global health education.

This study examines efforts to integrate social medicine into global health education and its potential to guide the new practice of structural competency. The methods employ participant observation and interviews with program coordinators and participants in a social medicine course. Areas of success included: pedagogical innovation, conscientizing course participants, decentralising global health practice, and promoting reflexivity. Accompanying these successes were points of friction, including: inequities in personal risk and mobility limitations among course participants, as well as complexities and nuances in unintentionally reproducing hierarchies of knowledge. Specifically, further recommendations from our research include: (1) incorporating innovative pedagogical approaches, which highlight social medicine practices outside the global north, prioritising opportunities for cross-collaboration among practitioners from the global south; (2) framing social theory as a bidirectional flow: global south traditions must be included in teaching social theory; (3) practising structural humility by highlighting the perspectives and expertise of communities experiencing social and structural marginalisation, while including strategies in organising and direct pathways to political engagement. These conclusions highlight how social medicine-based training can both build from and move beyond the competencies explicitly specified by the structural competency model to create a global health practice inclusive of diverse thought from around the world.

Set Down the Stethoscope.

In this moment of pandemic and social unrest, health workers feel overwhelming exhaustion, uncertainty, and powerlessness. At the same time, a deep spirit of resilience and a desire for innovation, discovery, and justice compel health workers to retain their commitment to serving patients and communities. This essay takes this context into consideration and proposes pragmatic steps toward a reimagined and reinvigorated future for our work as health workers.

Health Care Utilization Before and After the "Muslim Ban" Executive Order Among People Born in Muslim-Majority Countries and Living in the US.

Importance: The health effects of restrictive immigration and refugee policies targeting individuals from Muslim-majority countries are largely unknown. Objective: To analyze whether President Trump's 2017 executive order 13769, "Protecting the Nation from Foreign Terrorist Entry into the United States" (known as the "Muslim ban" executive order) was associated with changes in health care utilization by people born in targeted nations living in the US. Design, Setting, and Participants: This retrospective cohort study included adult patients treated at Minneapolis-St. Paul HealthPartners primary care clinics or emergency departments (EDs) between January 1, 2016, and December 31, 2017. Patients were categorized as (1) born in Muslim ban-targeted nations, (2) born in Muslim-majority nations not listed in the executive order, or (3) non-Latinx and born in the US. Data were analyzed from October 1, 2019, to May 12, 2021. Exposures: Executive order 13769, "Protecting the Nation from Foreign Terrorist Entry into the United States." Main Outcomes and Measures: Primary outcomes included the number of (1) primary care clinic visits, (2) missed primary care appointments, (3) primary care stress-responsive diagnoses, (4) ED visits, and (5) ED stress-responsive diagnoses. Visit trends were evaluated before and after the Muslim ban issuance using linear regression, and differences between the study groups after the executive order issuance were evaluated using difference-in-difference analyses. Results: A total of 252 594 patients were included in the analysis: 5667 in group 1 (3367 women [59.4%]; 5233 Black individuals [92.3%]), 1254 in group 2 (627 women [50%]; 391 White individuals [31.2%]), and 245 673 in group 3 (133 882 women [54.5%]; 203 342 White individuals [82.8%]). Group 1 was predominantly born in Somalia (5231 of 5667 [92.3%]) and insured by Medicare or Medicaid (4428 [78.1%]). Before the Muslim ban, primary care visits and stress-responsive diagnoses were increasing for individuals from Muslim-majority nations (groups 1 and 2). In the year after the ban, there were approximately 101 additional missed primary care appointments among people from Muslim-majority countries not named in the ban (point estimate [SE], 6.73 [2.90]; P = .02) and approximately 232 additional ED visits by individuals from Muslim ban-targeted nations (point estimate [SE], 3.41 [1.53]; P = .03). Conclusions and Relevance: Results of this cohort study suggest that after issuance of the Muslim ban executive order, missed primary care appointments and ED visits increased among people from Muslim-majority countries living in Minneapolis-St. Paul.

Race and Gender Differences in Medical Student Perspectives on Social Determinants of Health Education: A Single-Institution Survey Study.

PURPOSE: The field of medicine is becoming increasingly aware of the role that social determinants of health (SDH) play in shaping health and health outcomes. Organized medicine - including prominent physician groups and accreditation bodies - has endorsed SDH education as an integral component of medical school curricula. This study sought to describe medical student perspectives on the current state of SDH in preclinical curricula. METHODS: The authors developed a 9-item survey to assess time being spent on SDH and attitudes toward the current level of SDH content in preclinical curricula. All medical students at both campuses of a large public medical school were invited to participate between December 2019 and February 2020. RESULTS: Of 1010 medical students invited to participate, 515 (51.0%) responded. Of the 515 respondents, 480 (93.2%) reported spending at least 40 hours per week on medical school, and of those, 405 (84.4%) said they spend 0-2 hours on SDH. The majority of all respondents (62.1%; 320/515) felt the current level of focus on SDH is "not enough", while only eleven students (2.1%; 11/515) felt it is "too much". In a multiple logistic model, Black students were over four times as likely as white students (aOR 4.19; 95% CI 1.37-18.38) to feel the current level of focus on SDH is "not enough". Likewise, women were 2.3-times (aOR 2.30; 95% CI 1.52-3.49) as likely as men to feel the level of focus on SDH is "not enough". CONCLUSION: In practice, medical students are spending considerably less time learning SDH than is advised by consensus of expert educators and administrators. Over sixty percent of medical students do not feel the current level of focus on SDH is sufficient. Further study is needed to determine why women and racial minority students are significantly more likely to feel this way.

Development and dissemination of clinical decision support across institutions: standardization and sharing of refugee health screening modules.

OBJECTIVES: We developed and piloted a process for sharing guideline-based clinical decision support (CDS) across institutions, using health screening of newly arrived refugees as a case example. MATERIALS AND METHODS: We developed CDS to support care of newly arrived refugees through a systematic process including a needs assessment, a 2-phase cognitive task analysis, structured preimplementation testing, local implementation, and staged dissemination. We sought consensus from prospective users on CDS scope, applicable content, basic supported workflows, and final structure. We documented processes and developed sharable artifacts from each phase of development. We publically shared CDS artifacts through online dissemination platforms. We collected feedback and implementation data from implementation sites. RESULTS: Responses from 19 organizations demonstrated a need for improved CDS for newly arrived refugee patients. A guided multicenter workflow analysis identified 2 main workflows used by organizations that would need to be supported by shared CDS. We developed CDS through an iterative design process, which was successfully disseminated to other sites using online dissemination repositories. Implementation sites had a small-to-modest analyst time commitment but reported a good match between CDS and workflow. CONCLUSION: Sharing of CDS requires overcoming technical and workflow barriers. We used a guided multicenter workflow analysis and online dissemination repositories to create flexible CDS that has been adapted at 3 sites. Organizations looking to develop sharable CDS should consider evaluating the workflows of multiple institutions and collecting feedback on scope, design, and content in order to make a more generalizable product.

Where We Fall Down: Tensions in Teaching Social Medicine and Global Health.

BACKGROUND: As global health interest has risen, so too has the relevance of education on the social determinants of health and health equity. Social medicine offers a particularly salient framework for educating on the social determinants of health, health disparities, and health equity. SocMed and EqualHealth, 2 unique but related organizations, offer annual global health courses in Uganda, Haiti, and the United States, which train students to understand and respond to the social determinants of health through praxis, self-reflection and self-awareness, and building collaborative partnerships across difference. OBJECTIVES: The aim of this paper is to describe an innovative pedagogical approach to teaching social medicine and global health. We draw on the notion of praxis, which illuminates the value of iterative reflection and action, to critically examine our points of weakness as educators in order to derive lessons with broad applicability for those engaged in global health work. METHODS: The data for this paper were collected through an autoethnography of teaching 10 global health social medicine courses in Uganda and Haiti since 2010. It draws on revealing descriptions from participant observation, student feedback collected in anonymous course evaluations, and ongoing relationships with alumni. FINDINGS: Critical analysis reveals 3 significant and complicated tensions raised by our courses. The first point of weakness pertains to issues of course ownership by North American outsiders. The second tension emerges from explicit acknowledgment of social and economic inequities among our students and faculty. Finally, there are ongoing challenges of sustaining positive momentum toward social change after transformative course experiences. CONCLUSIONS: Although successful in generating transformative learning experiences, these courses expose significant fracture points worth interrogating as educators, activists, and global health practitioners. Ultimately, we have identified a need for building equitable partnerships and intentional community, embracing discomfort, and moving beyond reflection to praxis in global health education.

The necessity of social medicine in medical education.

Research and clinical experience reliably and repeatedly demonstrate that the determinants of health are most accurately conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. Increased appreciation of biosocial approaches have already driven change in premedical education and focused attention on population health in current U.S. health care reform. Medical education, however, places primary emphasis on biomedicine and often fails to emphasize and educate students and trainees about the social forces that shape disease and illness patterns. The authors of this Commentary argue that medical education requires a comprehensive transformation to incorporate rigorous biosocial training to ensure that all future health professionals are equipped with the knowledge and skills necessary to practice social medicine. Three distinct models for accomplishing such transformation are presented: SocMed's monthlong, elective courses in Northern Uganda and Haiti; Harvard Medical School's semester-long, required social medicine course; and the Lebanese American University's curricular integration of social medicine throughout its entire four-year curriculum. Successful implementation of social medicine training requires the institutionalization of biosocial curricula; the utilization of innovative, engaging pedagogies; and the involvement of health professions students from broad demographic backgrounds and with all career interests. The achievement of such transformational and necessary change to medical education will prepare future health practitioners working in all settings to respond more proactively and comprehensively to the health needs of all populations.

Poverty, global health, and infectious disease: lessons from Haiti and Rwanda.

Poverty and infectious diseases interact in complex ways. Casting destitution as intractable, or epidemics that afflict the poor as accidental, erroneously exonerates us from responsibility for caring for those most in need. Adequately addressing communicable diseases requires a biosocial appreciation of the structural forces that shape disease patterns. Most health interventions in resource-poor settings could garner support based on cost/benefit ratios with appropriately lengthy time horizons to capture the return on health investments and an adequate accounting of externalities; however, such a calculus masks the suffering of inaction and risks eroding the most powerful incentive to act: redressing inequality.

Of 'microbes' and 'millet': the practice of tea tea in northern Uganda.

In northern Uganda, incisions called tea tea are commonly placed on the chests of children outside of the biomedical setting to relieve respiratory distress. To better characterize tea tea, we administered a questionnaire to 224 caretakers, whose children had evidence tea tea cuts. In 148 cases (66.4%), the grandparents made the decision to have the cuts performed, at times against the wishes of the caretakers. One seventy-six (80.0%) of the patients were seen by a medical professional just prior to receiving the cuts. Traditional healers and grandmothers, respectively, performed the cuts in 164 (73.5%) and 42 (18.8%) cases. Caretakers paid at least 500 USh (US$0.29) for tea tea in 129 cases (57.8%) and nothing in 71 cases (31.4%). This study shows that tea tea is a healing practice with associated costs that is regularly advocated for and performed by grandmothers and traditional healers.

Framing HIV prevention discourse to encompass the complexities of war in northern Uganda.

In northern Uganda, physical and structural violence (political repression, economic inequality, and gender-based discrimination) increase vulnerability to HIV infection. In settings of war, traditional HIV prevention that solely promotes risk avoidance and risk reduction and assumes the existence of personal choice inadequately addresses the realities of HIV transmission. The design of HIV prevention strategies in northern Uganda must recognize how HIV transmission occurs and the factors that put people at risk for infection. A human rights approach provides a viable model for achieving this aim.

Access to generic antiretrovirals: inequality, intellectual property law, and international trade agreements.

The governments of numerous low- and middle-income countries are currently instituting rules that strengthen changes in domestic intellectual property legislation, often made to conform to the mandates of "free" trade agreements signed with the United States. These measures frequently include intellectual property provisions that extend beyond the patent law standards agreed upon in recent World Trade Organization negotiations, which promised to balance the exigencies of public health and patent holders. In this paper, we analyze the concern that this augmentation of patent law standards will curtail access to essential medicines, particularly as they relate to the AIDS pandemic. We critically examine the potential threats posed by trade agreements vis-à-vis efforts to provide universal access to antiretroviral medications and contend that the conditioning of economic development upon the strengthening of intellectual property law demands careful attention when public health is at stake. Finally, we examine advocacy successes in challenging patent law and conclude that greater advocacy and policy strategies are needed to ensure the protection of global health in trade negotiations.

Access to generic antiretrovirals: inequality, intellectual property law, and international trade agreements

The governments of numerous low- and middle-income countries are currently instituting rules that strengthen changes in domestic intellectual property legislation, often made to conform to the mandates of "free" trade agreements signed with the United States. These measures frequently include intellectual property provisions that extend beyond the patent law standards agreed upon in recent World Trade Organization negotiations, which promised to balance the exigencies of public health and patent holders. In this paper, we analyze the concern that this augmentation of patent law standards will curtail access to essential medicines, particularly as they relate to the AIDS pandemic. We critically examine the potential threats posed by trade agreements vis-à-vis efforts to provide universal access to antiretroviral medications and contend that the conditioning of economic development upon the strengthening of intellectual property law demands careful attention when public health is at stake. Finally, we examine advocacy successes in challenging patent law and conclude that greater advocacy and policy strategies are needed to ensure the protection of global health in trade negotiations.

Actualmente diversos países de renta media y baja están creando leyes de propiedad intelectual más rígidas, muchas veces para adaptarse a las exigencias de los tratados de "libre" comercio con los Estados Unidos. Tales medidas suelen incluir dispositivos que transcienden las normas sobre patentes negociadas recientemente en la Organización Mundial del Comercio, que prometían equilibrar las exigencias de la salud pública y las de patentes. Este artículo analiza la preocupación de que este endurecimiento restrinja el acceso a medicamentos esenciales, en particular en el contexto de la pandemia de SIDA. El artículo examina las amenazas potenciales creadas por los tratados comerciales contra los esfuerzos dirigidos para el acceso universal a los antirretrovirales, manteniendo que condicionar el desarrollo económico al endurecimiento de la legislación requiere una atención escrupulosamente justificada cuando la salud pública está en juego. Finalmente, se examinan algunos éxitos obtenidos por grupos de presión, concluyéndose que son necesarias más estrategias políticas y de presión para garantizar la protección de la salud mundial en las negociaciones sobre tratados internacionales de comercio.