Jonathan M. Metzl, M.D., the director of the Department of Medicine, Health and Society at Vanderbilt University, told members of the U.S. House of Representatives Committee on Ways and Means about how the COVID-19 pandemic exacerbated longstanding disparities in mental and physical health among Americans, largely based on economic standing.
Metzl emphasized in his March 2022 remarks about the need to implement medical education and practice based on structural competency, which factors in social, economic and other influences to provide a more holistic perspective. The concept was developed by Metzl and a colleague decades ago, launching a structural-competency movement worldwide.
Poverty Weaves its Web
Discover: Your work focuses on helping doctors understand and address the web of social, economic and political issues that affect individual health, a web that has been described as being spun by poverty as the spider. How has the pandemic affected these efforts?
Metzl: The pandemic has highlighted the fact that so many things people see as individual health problems actually grow out of much larger forces, which are tied not just to the biology of one person’s body but also to decisions we’ve made as a society. These include politics, economics, housing, transportation, and where resources are invested and disinvested.
We saw dramatically different impacts of the pandemic on people of color in low-income communities, as compared to people in wealthier areas. Such disparities are nothing new.
The clinical presentations of both rich and poor people grow out of economic and political forces that produce health inequalities in the first place. We hear about low-income African Americans being unable to comply with doctors’ orders to take medications with food, and it’s not because they harbor cultural mistrust of the medical establishment but because they live in food deserts. We hear about Central American immigrants at risk for type 2 diabetes refusing to exercise, and it’s not because they don’t know about the benefits of losing weight but because the neighborhoods they live in have no gyms or sidewalks or parks.
We also know that small numbers of well-to-do white people pay for health care out of pocket, not because they don’t qualify for coverage, but because the tax advantages they receive allow them to pay cash for office visits with elite practitioners who don’t take insurance.
Beyond ‘Cultural Competency’
Discover: As the U.S. has grown increasingly diverse, medicine has stressed cultural competency for providers. Why is structural competency a better framework?
Metzl: Medicine embraced cultural competency as a corrective measure after decades of generally ignoring diversity issues. The basic idea was that having a culturally sensitive provider reduces the impact of stigma on a patient and can improve health outcomes. In practice, the application of the concept has sometimes devolved into the acceptance of stereotypes. It maintains a micro-focus on a person’s individual choices, ignoring important macro-level forces. We now know this is simplistic and unrealistic.
Research in many fields has proven that stigma, racism and poverty directly affect health. We know that, at the level of gene methylation, high-stress impoverished environments can produce risk factors for disease lasting generations. Neuroscientists have found physical links between poverty and reduced brain development and increased mental illness. Experts have shown that people living in high-poverty neighborhoods can lower their risk of major depression, obesity and diabetes by moving to lower-poverty neighborhoods.
Starting with a publication I co-authored with a colleague at New York University in 2014, I launched a movement calling for medicine to shift its focus and develop structural competencies about ways that material realities play out in patients’ bodies and minds.
Physicians get this. In one Robert Wood Johnson survey, 85 percent of providers agreed that “unmet social needs are directly leading to worse health for all Americans.” They also expressed uncertainty about how to help.
The Case of Mrs. Jones
Discover: Can you share an example of how a structural-competency mindset can impact a patient encounter?
Metzl: Picture a young white resident from Utah, “Dr. Cassidy,” in a Bronx hospital meeting a 65-year-old minority woman, “Mrs. Jones,” who arrives late for the appointment and isn’t taking her prescribed blood pressure medicine. If Cassidy adopts a cultural competence framework, they might ask Mrs. Jones questions about her background and her attitudes towards medications. Admittedly those factors are relevant, but a structural competency approach would involve exploring factors beyond the exam room that could matter.
Medical students studying this case might consider the pharmaco-economics involved. Is her prescription for a brand name or generic drug? Where can she fill it, and what policies affect the cost? Relevant questions might include the number of busses or subways Mrs. Jones had to take to reach the office; they might include a consideration of how the time allotted for the visit influences the kinds of conversations that do or do not take place.
Thinking this way helps physicians see that the political economics of health care in America impact them, as well as their patients.
Progress is Essential
Discover: Speaking of medical students, how has the structural-competency approach changed medical education?
Metzl: Since 2014, this idea has fostered a whole movement, with its own literature. The key principles we outlined as essential to a structural-competency approach are now taught in medical schools worldwide.
I believe that structural competency concepts ought to be discussed widely. And, recently I chaired a panel addressing these issues with an undergraduate audience. Several leaders at Vanderbilt, including Wes Ely and Alex Jahangir, participated.
Discover: When you presented these ideas to Congress, how did their leaders respond?
Metzl: Improving our approach to health care is so politicized. Everyone seemed to see just a small part of the problem, when we need to think broadly.
Concept in Action
Discover: Can you describe examples of efforts based in a structural-competency approach?
Metzl: Student-led initiatives provide good examples. Here at Vanderbilt, a medical student launched the Nashville Mobile Market to bring fresh, healthy food to food deserts. At Harvard, an undergraduate founded Health Leads to support hospitals and clinics in better connecting patients with resources like food, housing and transportation.
Today, insurers provide a variety of tools to allow providers and researchers to assess specific ways in which structural vulnerabilities affect patients. Researchers all over are doing community-based, participatory studies, engaging community members as equal partners in every stage of an investigation, from deciding what questions matter to disseminating results.
The list of efforts that put structural competency into action could go on and on.
Mobilizing for Better Care
Discover: How would you like to see physicians make their voices heard on the relevant issues?
Metzl: There is no avoiding politics if physicians sincerely want to help patients live healthier lives. Health-care practitioners need to understand how financial, legal, and governmental decisions play out in patients’ lives. Then we need to mobilize to support ethical decisions in all these realms that directly affect well-being.
I don’t tell people who to vote for, but you do have to look broadly and deeply at the life circumstances of the people you treat. Working with the American Medical Association, which has invited all its members to join the structural-competency movement, is a good place to start.