‘Structural humility’ and ‘socio-professional activism’ – adding to the equity lexicon for practitioners

[Estimated reading time: 6mins]

During my research and praxis over the years I have sometimes struggled to articulate with brevity some of the fundamental characteristics that practitioners should strive to embody if they aim to contribute to positive social change in healthcare and education.

This led me to proposing, in late 2021 on twitter, ‘structural humility’ and ‘socio-professional activism’ as two new terms that may contribute to thinking and action towards social justice. In this blog I explain things in a little more detail…

Firstly, let’s look at this quote from a recent research paper entitled ‘Physical pain, gender, and the state of the economy in 146 nations’:

“Economic worry can create physical pain...[its level] in a nation depends on the state of the economy. Pain is high when the unemployment rate is high. That is not because of greater pain among people who lose their jobs - it extends far beyond that into wider society…[and the] increase in physical pain in a downturn is experienced disproportionately.”

(Macchia and Oswald, 2021)

On first reading, the above findings help us to understand how social determinants of health impact on health and wellbeing. In this case the poverty, pressures and precarity associated with lower and middle-class employment, particularly in an economic downturn. This is incredibly useful in helping clinicians better understand the context of their patients. It also has great value in helping researchers to better understand the complexities inherent in human morbidity. The ‘social’ part of a dynamic ‘biopsychosocial’ (BPS) model of health (Lehman, David and Gruber, 2017), if you will. Some have critiqued the biopsychosocial model of health (see here for a nice summary), with a common conclusion that “we may need to better apply the BPS model rather than move beyond it” (Cormack, 2019).  

Which leads us to a deeper reading of the opening quote, which I believe is even more helpful. For what are we to deduce from the finding that ‘pain levels depend on the state of the economy’? Are we, for example, to understand a government policy of unnecessary austerity as a contributing factor in pain or ill health? Or how neoliberalism in healthcare has turned patients not just into consumers, but into atomised ‘immoral’ individuals responsible for their own ill-health through choice alone? Are we, therefore, to think more carefully about how we vote as clinicians and educators? Or how we work in, and with, communities towards best practice and optimal outcomes? Is ignoring the ramifications of our personal and collective politics acting in the best interests of our patients, particularly those from marginalised groups? Do such questions invoke our professional and ethical responsibilities as members of professional bodies? Does it, by extension, call forth those professional bodies to be more active in the socio-political?

“politics and healthcare are inextricable intertwined”

(Heer-Stavert, 2020)

Whatever your personal opinion is on the answers to those questions, the provocation may have you considering how wider society impacts on the individual patient, and how the individual practitioner (and their collective representative body) impacts on wider society. This understanding of society as something that produces or reinforces conditions which contribute to disproportionate differences in outcomes in health (and in education, justice, employment…) can be termed ‘structural competency’. Structural competency therefore indicates one’s level of awareness and understanding of the inequalities entrenched in the overall system of society (i.e. ‘systemic’) and it its sub-systems, such as organisations, businesses and communities (i.e. ‘institutional’).

I argue that whilst the term ‘structural competency’ is useful and necessary for understanding and action towards ‘health justice’ (Benfer, 2015), it is limited for the following three reasons:

1. The term ‘structural’ implies a focus solely on ‘structures’, which risks essentialising a disconnect between the individual and collective (social justice activism requires solidarity to create systemic change)
2. The term ‘competency’ risks creating a pseudointellectual gap between the ‘haves’ and the ‘have nots’. It is an intellectual sleight of hand that empowers those who claim expertise, and disenfranchises those who are too anxious to embark on learning more or taking action for fear of being labelled incompetent
3. ‘Competency’ also suggests a banking model of education that reproduces the colonial power imbalance between expert and student that is antithetical to liberation and social justice activism (Freire, 1968)

You may also have heard of the terms ‘cultural competency’ (Danso, 2018) and ‘cultural humility’ (Mosher et al., 2017) that emerged at the end of the 20^th century. Both have overlapping concerns and contested interpretations, and both have valuable, alternative routes to a more ethical and inclusive healthcare. However, I suggest the terms bear similar limitations as outlined above, with the additional drawback of a paternalistic and multiculturalist interpretation of race/ism that both slows and limits progress (see Lentin and Titley, 2011, for more on the problems with 'multiculturalism').

So, what might be a better term for how practitioners understand the widespread and persistent health inequities that advantage dominant groups (Nixon, 2019) and have their social, political and economic roots in the legacies of colonialism and functions of late-stage capitalism? How might structural competency and cultural humility be reframed in a way that embraces thinking critically about the connection between themselves - as autonomous practitioners - and the system that reproduces healthcare inequalities for marginalised groups?

I propose the term ‘structural humility’ (Cole, 2021). With structural humility we immediately have a connection between the systemic and the personal, between knowledge and growth, and between empowerment and vulnerability.

‘Humility’ explicitly centres a recognition of ourself  within the structures of oppression. I retain ‘structural’ because it rightly asks of us to understand power dynamics that govern the inequitable distribution of resources and opportunities and which bestow differential and unjust proximities to health, wealth and freedom; I use ‘humility’ because it implores us to understand our position within these power dynamics. That is to say, it should motivate us to think about how we may be positioned as complicit in reproducing structural inequalities, how we might be advantaged by the system, and – crucially - how we might be able develop our awareness of why we think, feel and act in ways that can be barriers to a solidarity of community action (Coote and Angel, 2014) that is necessary to overcome medical hegemony (Holst, 2020) in the struggle for health justice.

So - one might now ask, 'what to do with these notions of structural humility'? Well, each person is an individual, and therefore every practitioner will have their own ways, means and opportunities to engage in activism.

Whichever route/s is/are taken, if the reflection, engagement and action takes place within or related to professional practice, I have called this ‘socio-professional activism’. 

I believe this is one of the the most important of our duties as healthcare professionals or as educators, and I hope that we - as individuals and as professional bodies - join in agreement and action. 

Please comment below with your own interpretation of socio-professional activism, sharing examples of what you do in your profession. We can all learn from and be inspired by each other’s approaches!

Thanks for reading.

 

Post-script: Since publishing this blog piece I have found the term 'structural humility' in a 2014 paper by Metzl & Hansen, so cite that here, and screenshot (it's a great paper by the way):

Post-script 2: subsequently found two further uses of the phrase 'structural humility': one by Camacho & Rivera-Salgado (2020) in reference to researching Indigenous Mexican farmworkers in California, and another by Davis (2020) in reference to space-time ontological research.

Post-script 3: In September 2022, I found this excellent paper by Courtney Sarkin (2019), who uses a 'cultural humility' concept that shares overlapping themes https://www.iastatedigitalpress.com/jctp/article/8207/galley/7907/view/

References

• Benfer, E.A. (2015) ‘Health Justice: A Framework (and Call to Action) for the Elimination of Health Inequity and Social Injustice’, The American University Law Review, 65(2), pp. 275–351.
• Camacho, S., & Rivera-Salgado, G. (2020). Lost in translation “en el Fil”: Actualizing structural humility for Indigenous Mexican farmworkers in California. Latino Studies, 18(4), 531-557.
  
• Cole, M. (2021) ‘What is “structural humility”? Building on previous insights drawn from cultural humility and structural competency, “structural humility” is necessary (yet not solely sufficient) for social justice activism. Hope it’s useful. https://t.co/d9xbZGrr6o’, @Cole_Therapy_Ed, 1 November. Available at: https://twitter.com/Cole_Therapy_Ed/status/1455296067705229321 (Accessed: 16 November 2021).
• Coote, A. and Angel, J. (2014) ‘Solidarity: Why it matters for a new social settlement’, p. 34.
• Cormack, B. (2019) Have we ballsed up the BIOPSYCHOSOCIAL model?, Cor Kinetic. Available at: https://cor-kinetic.com/have-we-ballsed-up-the-biopsychosocial-model/ (Accessed: 16 November 2021).
• Danso, R. (2018) ‘Cultural competence and cultural humility: A critical reflection on key cultural diversity concepts’, Journal of Social Work, 18(4), pp. 410–430. doi:10.1177/1468017316654341.
• Davis, C. A. (2020). Structural Humility.
  
• Freire, P. (1968) ‘Pedagogy of the Oppressed’, p. 4.
• Heer-Stavert, S. (2020) ‘Covid-19: healthcare and politics are inexorably intertwined’, BMJ, 369, p. m2532. doi:10.1136/bmj.m2532.
• Holst, J. (2020) ‘Global Health – emergence, hegemonic trends and biomedical reductionism’, Globalization and Health, 16(1), p. 42. doi:10.1186/s12992-020-00573-4.
• Lehman, B.J., David, D.M. and Gruber, J.A. (2017) ‘Rethinking the biopsychosocial model of health: Understanding health as a dynamic system’, Social and Personality Psychology Compass, 11(8), p. e12328. doi:10.1111/spc3.12328.
• Lentin, A. and Titley, G. (2011) The Crises of Multiculturalism: Racism in a Neoliberal Age. Zed Books Ltd.
• Macchia, L. and Oswald, A.J. (2021) ‘Physical pain, gender, and economic trends in 146 nations’, Social Science & Medicine, p. 114332. doi:10.1016/j.socscimed.2021.114332.
• Metzl, J.M. and Hansen, H. (2014) ‘Structural competency: Theorizing a new medical engagement with stigma and inequality’, Social Science & Medicine, 103, pp. 126–133. doi:10.1016/j.socscimed.2013.06.032.
• Mosher, D.K. et al. (2017) ‘Cultural humility: A therapeutic framework for engaging diverse clients’, Practice Innovations, 2(4), pp. 221–233. doi:10.1037/pri0000055.
• Nixon, S.A. (2019) ‘The coin model of privilege and critical allyship: implications for health’, BMC Public Health, 19(1), p. 1637. doi:10.1186/s12889-019-7884-9.