Helena Hansen

Structural competency: Theorizing a new medical engagement with stigma and inequality

This paper describes a shift in medical education away from pedagogic approaches to stigma and inequalities that emphasize cross-cultural understandings of individual patients, toward attention to forces that influence health outcomes at levels above individual interactions. It reviews existing structural approaches to stigma and health inequalities developed outside of medicine, and proposes changes to U.S. medical education that will infuse clinical training with a structural focus. The approach, termed “structural competency,” consists of training in five core competencies: 1) recognizing the structures that shape clinical interactions; 2) developing an extra-clinical language of structure; 3) rearticulating “cultural” formulations in structural terms; 4) observing and imagining structural interventions; and 5) developing structural humility. Examples are provided of structural health scholarship that should be adopted into medical didactic curricula, and of structural interventions that can provide participant-observation opportunities for clinical trainees. The paper ultimately argues that increasing recognition of the ways in which social and economic forces produce symptoms or methylate genes then needs to be better coupled with medical models for structural change.

Integrating Buprenorphine Treatment into Office-based Practice: a Qualitative Study

BACKGROUNDDespite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians’ attitudes towards this new medical practice has been largely neglected.OBJECTIVETo identify facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers.DESIGNQualitative study using individual and group semi-structured interviews.PARTICIPANTSTwenty-three practicing office-based physicians in New England.APPROACHInterviews were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team.RESULTSEighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians’ perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians’ practices.CONCLUSIONSAddressing physicians’ perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices.

Issues for DSM-V: the role of culture in psychiatric diagnosis.

Renato D. Alarcón, MD, MPH,* Anne E. Becker, MD, PhD, ScM,†‡ Roberto Lewis-Fernández, MD,§¶ Robert C. Like, MD, MS, Prakash Desai, MD,** Edward Foulks, MD, PhD,†† Junius Gonzales, MD, MPH,‡‡ Helena Hansen, MD, PhD,§§ Alex Kopelowicz, MD,¶¶ Francis G. Lu, MD, María A. Oquendo, MD,*** and Annelle Primm, MD, MPH†††‡‡‡ for the Cultural Psychiatry Committee of the Group for the Advancement of Psychiatry

Variation in use of buprenorphine and methadone treatment by racial, ethnic, and income characteristics of residential social areas in New York City.

National data indicate that patients treated with buprenorphine for opiate use disorders are more likely to be White, highly educated, and to have greater incomes than those receiving methadone, but patterns of buprenorphine dissemination across demographic areas have not been documented in major metropolitan areas where poverty, minority populations and injection heroin use are concentrated. Rates of buprenorphine and methadone treatment are compared among areas of New York City defined by their income and ethnic/racial composition. Residential social areas (hereinafter called social areas) were defined as aggregations of ZIP codes with similar race/ethnicity and income characteristics, and were formed based on clustering techniques. Treatment rates were obtained for each New York City ZIP code: buprenorphine treatment rates were based on the annual number of buprenorphine prescriptions written, and the methadone treatment rate on the number of methadone clinic visits for persons in each ZIP code. Treatment rates were correlated univariately with ethnicity and income characteristics of ZIP codes. Social area treatment rates were compared using individual ANOVA models for each rate. Buprenorphine and methadone treatment rates were significantly correlated with the ethnicity and income characteristics of ZIP codes, and treatment rates differed significantly across the social areas. Buprenorphine treatment rates were highest in the social area with the highest income and lowest percentage of Black and Hispanic residents. Conversely, the methadone treatment rate was highest in the social area with the highest percentage of low income and Hispanic residents. The uneven dissemination of 0pioid maintenance treatment in New York City may be reflective of the limited public health impact of buprenorphine in ethnic minority and low income areas. Specific policy and educational interventions to providers are needed to promote the use of buprenorphine for opiate use disorders in diverse populations.

The Craft of Writing: A Physician‐Writer's Workshop for Resident Physicians

AbstractINTRODUCTION: How can residency programs help trainees address conflicting emotions about their professional roles and cultivate a curiosity about their patients’ lives beyond their diseases? We drew on the medical humanities to address these challenges by creating an intensive writing workshop for internal medicine residents. AIM: To help participants become better physicians by reflecting on their experiences and on what gives meaning to work and life. This paper describes the workshop and how residents were affected by the focus on the craft of writing. SETTING: A group of 15 residents from 3 training programs affiliated with 1 institution. PROGRAM DESCRIPTION: We engaged the expertise of physician-writer Abraham Verghese in planning and facilitating the 2 and one-half day workshop. Residents’ submissions were discussed with a focus on the effectiveness of the writing. We also conducted a focus group with participants to evaluate the workshop. PROGRAM EVALUATION: Themes in the writing included dysphoria, impotence of the physician, and the healing power of compassion. Our focus group data suggested that this workshop served as a creative outlet from the rigors of medicine, created a sense of community among participants, enhanced both self-awareness and awareness of their patients’ lives, and increased intra-institutional and extra-institutional interest in writing and the residency program. DISCUSSION: Teaching creative writing to residents in an intensive workshop may deepen interactions with peers and patients, improve writing skills, and increase interest in writing and the residency program.

From quarantine to condoms: Shifting policies and problems of HIV control in Cuba

This study reviews HIV prevention in Cuba in light of (1) the liberalization of HIV quarantine, (2) the growth in tourism, and (3) the aggressive system of public health promotion. Sixty‐two key informants, including Cubans who are HIV‐positive, at risk, or working as health professionals, were interviewed during June and July of 1996. Findings include: (1) there is a common public perception that the governments national HIV screening and contact tracing system obviates the need for individual precaution; and (2) both commercial sex workers and men who have sex with men believe that legal and social forces hinder their indigenous HIV prevention efforts. A well developed system of preventive health care offers the potential for effective HIV prevention. The fact that Cuban officials use the success of their HIV/AIDS control program to promote national pride may retard appropriate changes in their response to currently rising levels of infection.

Drug treatment, health, and social service utilization by substance abusing women from a community-based sample

Background:Substance abuse is an escalating problem among poor urban Latina women; little is known about their access to drug treatment and to needed social and health services. Objective:Our objectives were to (1) examine the need and use of substance abuse treatment, health services, government entitlement programs, and social service programs among cocaine and heroin using Puerto Rican women and (2) identify whether service use predicts their prospective entry into drug treatment. Research Design:This was a 3-wave longitudinal study of community substance abusing women evaluated on substance abuse and dependence using diagnostic measures, and hair and urine toxicological screens. Information was collected on self-reported need and receipt of substance abuse treatment, social services, general health services, and government entitlement programs. Subjects:A community sample of cocaine-, crack-, and/or heroin-using women from copping areas in low-income urban centers of Puerto Rico were interviewed in 1997–1998 with 2 follow-up periods. Results:Drug treatment, health, and social service utilization were low relative to need for services throughout all data waves. Social service utilization predicted prospective entry into drug treatment but not contacts with general health services or government entitlement programs. Conclusion:Drug-abusing women in low-income urban areas in Puerto Rico have substantial unmet substance abuse treatment, health, and social service needs. Mandated treatment by social service agencies may explain their clients’ higher likelihood of entering drug treatment. Building linkages between service sectors to augment entry into drug treatment is essential for meeting the complex needs of this underserved population.

Buprenorphine and methadone treatment for opioid dependence by income, ethnicity and race of neighborhoods in New York City

BACKGROUND Geographic and demographic variation in buprenorphine and methadone treatment use in U.S. cities has not been assessed. Identifying variance in opioid maintenance is essential to improving treatment access and equity. PURPOSE To examine the differential uptake of buprenorphine treatment in comparison to methadone treatment between 2004 and 2013 in neighborhoods in New York City characterized by income, race and ethnicity. METHODS Social area (SA) analysis of residential zip codes of methadone and buprenorphine patients in NYC, which aggregated zip codes into five social areas with similar percentages of residents below poverty, identifying as Black non-Hispanic and as Hispanic, to examine whether treatment rates differed significantly among social areas over time. For each rate, mixed model analyses of variance were run with fixed effects for social area, year and the interaction of social area by year. RESULTS Buprenorphine treatment increased in all social areas over time with a significantly higher rate of increase in the social area with the highest income and the lowest percentage of Black, Hispanic, and low-income residents. Methadone treatment decreased slightly in all social areas until 2011 and then increased bringing rates back to 2004 levels. Treatment patterns varied by social area. CONCLUSIONS Buprenorphine treatment rates are increasing in all social areas, with slower uptake in moderate income mixed ethnicity areas. Methadone rates have remained stable over time. Targeted investments to promote public sector buprenorphine prescription may be necessary to reduce disparities in buprenorphine treatment and to realize its potential as a public health measure.

Ethnography of health for social change: impact on public perception and policy.

Social Science & Medicine 99 (2013) 116e118 Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed Introduction Ethnography of Health for Social Change: Impact on public perception and policy Introduction This special issue addresses a core problem of social science: the relationship of research to public perception and policy. It focuses on the potential impact of ethnographic research on the way its au- diences see health problems, conduct their professional and per- sonal lives, and become politically active. How can ethnography foster public engagement in health issues? Ethnography has an established role in health research. It eluci- dates the cultural logics driving health related behavior, and the un- examined assumptions that frame problems of relevance to health. It places these findings in historical, economic and political context in ways that quantitative research alone does not. And given the widespread use of narrative in mass media’s shaping of public opinion in the U.S., ethnographic narratives promise to make a distinct contribution to public perceptions and policy. Medical an- thropology and sociology have long been employing ethnographic methods to answer specific health and medicine-related questions. They have had a demonstrable impact on professional and organi- zational practices as well as on our theoretical understandings of health and medicine. But what broader effects might ethnographic work, ranging from theoretical to applied, have on public discourse and policy agendas? This is a question for cultural anthropology and qualitative soci- ologydfields that have called for self-examination regarding the public relevance of their work (Burawoy, 2009; Gans, 2010). It is also a question for qualitative public health and policy researchers, whose methodologies may be less established within their larger disciplines. In the U.S., national meetings of the American Anthro- pological Association, and academic publishers such as the editors of the journal Ethnography and of the University of California Press book series on Public Anthropology, strive to bring ethnography to bear on issues of public importance. Leaders in a movement within academia to promote public ethnography have defined it as “The type of research and writing that directly engages with the critical social issues of our time.Authors of such works passionately inscribe, translate, and perform their research in order to.emo- tionally engage, educate, and move the public to action.” (Tedlock, 2007) Yet there is little consensus on how to achieve this goal. Articles in this special issue describe ethnographic research of relevance to health and consider the actual or potential impact of their findings on public debate and policy. In order to demonstrate cross cutting core issues, as well as the specificity and diversity of the ways that ethnographic research reaches larger publics in particular contexts, we deliberately include ethnographers working in geographically and thematically diverse settings. 0277-9536/

White opioids: Pharmaceutical race and the war on drugs that wasn’t

e see front matter O 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2013.11.001 Contributors to this issue cluster around three cross cutting topics in which ethnography has historically played a prominent role: 1) critical perspectives on global health; 2) marginalizing pro- cesses of poverty, stigma and violence; and 3) community based participation and advocacy. First, global health initiatives have required the fine grained and interpretive perspective offered by ethnographers, which has led to indispensable insights among global health practitioners and agencies about the ways that concepts and interventions do, or do not, translate across borders, languages and cultural groups (Janes, 2010; Kleinman, 2010; Nichter, 2008). In fact, ethnographers are often able to explain counterintuitive outcomes when health in- terventions are transported from one locale to another. Second, ethnographers have historically had unique access to marginalized groups, and attended to their on-the-ground lived ex- periences, illuminating both the local mechanisms by which larger policies or institutions negatively impact health, and the ways that marginalized groups attempt to adapt to and resist unfavorable pol- icies and institutions (Hammersley & Atkinson, 2007; Kleinman, Das, & Lock, 1997). Third, when these groups or health organiza- tions attempt to advocate for themselves against the larger struc- tural forces that entrench health and social inequalities, ethnographers are often those who document this advocacy and its symbolic and material sources. The ethnographic stance of rep- resenting alternative world views lends itself to envisioning alter- native politics and institutions. It also lends itself to participatory research in which research subjects shape the questions and prod- ucts of health research itself (Israel, 2005; Minkler & Wallerstein, The ethnographic record is rich with research that illuminates health inequalities and calls for social change as health intervention. Ethnographers are often called upon to assess the effects of profes- sional and institutional practices on health outcomes. And a growing number of ethnographers are “studying up; ” analyzing the cultural frames and social practices of large institutions, professionals, scien- tists, marketers, journalists and policy-makers themselves. Yet the ways that their diverse ethnographies inform publics and policy makers have seldom been examined in a systematic way. This special issue takes up the question of how ethnographic research can uniquely contribute to public perception and policy surrounding health issues. It poses this question to academic, theo- retical ethnographers who pursue topics of public interest. To that end, this issue assembles the work of ethnographers who strive to illuminate the social mechanisms of health disparities, as well as an anthropologist-cum-magazine publisher, an online editor, a policy- maker-cum-visual ethnographer, and a local and national health official who comment on these ethnographic perspectives from