Jonathan M. Metzl

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.

Medicalisation in the 21st century: Introduction

What is medicalisation? What are its causes and eff ects? Who benefi ts from medicalisation, and who is harmed? What, if anything, should be done about it? Answers to these questions would have seemed quite obvious in the 1970s, when the term entered academic and medical publications: medicalisation, the expansion of medical authority into the domains of everyday existence, was promoted by doctors and was therefore a force to be rejected in the name of specifi c kinds of liberation. Ivan Illich’s 1975 book, Limits to medicine: medical nemesis, was the most infl uential early example of this usage of the term medicalisation. Illich, a philosopher, argued that the medical establishment posed a “threat to health” through the production of clinical, social, and cultural “iatrogenesis”. For Illich, Western medicine’s notion of issues of healing, ageing, and dying as medical illnesses eff ectively “medicalised” human life, rendering individuals and societies less able to deal with these “natural” processes. Illich’s assessment of professional medicine, and particularly his use of the term medicalisation, quickly caught on, as critiques of the expansive categories of illness and health appeared throughout a vast array of professional literatures throughout the 1970s and 1980s. 30 years on, the defi nition of medicalisation is more complicated, if for no other reason than because the term is used so widely: a Google search for “medicalisation” in 2006 yields more than 358 000 hits. Many contemporary critics position pharmaceutical companies in the space once held by doctors as the supposed catalysts of social transformation. Titles such as The making of a disease or Sex, drugs, and marketing critique the pharmaceutical industry for shunting everyday problems into the domain of professional biomedicine. At the same time, to suggest that society simply reject drugs or drug companies in much the same ways Illich suggested it “liberate” itself from the medical system is implausible. The same drugs that treat deviances from societal norms also help many people live their lives. Even scholars who critique the societal implications of brand-name drugs generally remain open to these drugs’ curative eff ects—a far cry from earlier calls for a revolution against the biomedical establishment. The physician’s role in this present-day notion of medicalisation is similarly complex. On one hand, the doctor remains an authority fi gure who prescribes pharmaceuticals to patients. Whereas on the other, in the USA at least, ubiquitous consumer-directed advertisements instruct patients to ask for particular drugs by name, thereby creating a conversation between consumer and drug company that threatens to cut the doctor out of the loop. The role of patients in this economy has also changed. Once regarded as passive victims of medicalisation, patients can now occupy active positions as advocates, consumers, or even agents of change. In June, 2005, an interdisciplinary group of scholars gathered in New York City, USA to discuss the clinical, philosophical, and political implications of medical isation. The group’s central question was whether, in the industrialised world, medicalisation remains a viable notion in an age dominated by complex and often contradictory interactions between medicine, pharmaceutical companies, and culture at large. Participants represented a variety of disciplines, including psychiatry, sociology, anthropology, history, critical race theory, and gender studies. As such, topics ranged from the economics of medicalisation to the creation and perpetuation of medicalised forms of identity and citizenship. The next fi ve papers in this series are those that were presented at the meeting in New York.

Cultural sutures : medicine and media

Medicine and the media exist in a unique symbiosis. Increasingly, health-care consumers turn to media sources—from news reports to Web sites to tv shows—for information about diseases, treatments, pharmacology, and important health issues. And just as the media scour the medical terrain for news stories and plot lines, those in the health-care industry use the media to publicize legitimate stories and advance particular agendas. The essays in Cultural Sutures delineate this deeply collaborative process by scrutinizing a broad range of interconnections between medicine and the media in print journalism, advertisements, fiction films, television shows, documentaries, and computer technology. In this volume, scholars of cinema studies, philosophy, English, sociology, health-care education, women’s studies, bioethics, and other fields demonstrate how the world of medicine engages and permeates the media that surround us. Whether examining the press coverage of the Jack Kevorkian–euthanasia controversy; pondering questions about accessibility, accountability, and professionalism raised by such films as Awakenings, The Doctor, and Lorenzo’s Oil; analyzing the depiction of doctors, patients, and medicine on E.R. and Chicago Hope; or considering the ways in which digital technologies have redefined the medical body, these essays are consistently illuminating and provocative. Contributors. Arthur Caplan, Tod Chambers, Stephanie Clark-Brown, Marc R. Cohen, Kelly A. Cole, Lucy Fischer, Lester D. Friedman, Joy V. Fuqua, Sander L. Gilman, Norbert Goldfield, Joel Howell, Therese Jones, Timothy Lenoir, Gregory Makoul, Marilyn Chandler McEntyre, Faith McLellan, Jonathan M. Metzl, Christie Milliken, Martin F. Norden, Kirsten Ostherr, Limor Peer, Audrey Shafer, Joseph Turow, Greg VandeKieft, Otto F. Wahl

Voyeur Nation? Changing Definitions of Voyeurism, 1950–2004

This boom in the vicarious is the hallmark of a people with not enough time on their hands, people who have a to-do list instead of a life, people for whom the download can never be quick enough. An entire nation living at warp speed has no time for tedium. What could be easier than cutting out the middleman of our own daily existence and instead watching the high points of life on tape? (Anna Quindlen, “Too Busy to Have a Life of Your Own? There’s Always the Vicarious Voyeurism of Reality TV”)1

'Mother's Little Helper': The Crisis of Psychoanalysis and the Miltown Resolution

In the 1960s and 1970s, psychopharmacological medications seemed to burst onto the American scene. Popularised and problematised in the notion that these drugs were ‘Mother’s Little Helpers’, the pills became known as the treatments of choice for the pressures of motherhood, singlehood and other historically specific forms of essentialised womanhood. ‘Doctor please/Some more of these’ sang the Rolling Stones in the song ‘Mother’s Little Helper’. 1 Jaqueline Susann suggested that psychopharmaceuticals were a ‘woman’s best friend’ when it came to dealing with the pressures of working in a man’s world, while Barbara Gordon informed ‘millions of Americans’ about the untoward effects of a woman’s treatment with, addiction to, and withdrawal from Valium. 2 And most important, nearly all of the research supporting the notion that psychopharmacological medications were over-prescribed to mothers was conducted during the benzodiazepine craze between 1965 and 1979. 3

If direct-to-consumer advertisements come to Europe: lessons from the USA

704 www.thelancet.com Vol 369 February 24, 2007 The appearance of racialised drugs on pharmacists’ shelves only increases the need to attend to the myriad social sources of disparities in morbidity and mortality. Although to turn a profi t from fi ghting racial discrimination is diffi cult, eff ective medical care demands continued awareness of the complex social dimensions of diseases, such as hypertension and cancer.

The Interdependence of African American Men's Definitions of Manhood and Health

In this article, we explore themes that cut across how 24- to 77-year-old African American men define manhood and health. Utilizing a thematic approach, we analyzed data from 9 focus groups (N = 73). We found that manhood and health were relational constructs that are interrelated in mens minds and experiences. Manhood and health were defined by the characteristics men embody, the behaviors men engage in, and the goals and values men had to positively influence their families and communities. Thus, manhood and health are interdependent constructs and their interrelationship should be considered in efforts to promote African American mens health.

Structural competency in the U.S. healthcare crisis: putting social and policy interventions into clinical practice

This symposium of the Journal of Bioethical Inquiry illustrates structural competency: how clinical practitioners can intervene on social and institutional determinants of health. It will require training clinicians to see and act on structural barriers to health, to adapt imaginative structural approaches from fields outside of medicine, and to collaborate with disciplines and institutions outside of medicine. Case studies of effective work on all of these levels are presented in this volume. The contributors exemplify structural competency from many angles, from the implications of epigenetics for environmental intervention in personalized medicine to the ways clinicians can act on fundamental causes of disease, address abuses of power in clinical training, racially desegregate cities to reduce health disparities, address the systemic causes of torture by police, and implement harm-reduction programs for addiction in the face of punitive drug laws. Together, these contributors demonstrate the unique roles that clinicians can play in breaking systemic barriers to health and the benefit to the U.S. healthcare system of adopting innovations from outside of the United States and outside of clinical medicine.

Making History: Lessons from the Great Moments Series of Pharmaceutical Advertisements

The authors shed light on present-day pharmaceutical advertisements by looking back to an important early chapter in pharmaceutical company–sponsored promotion: the Great Moments in Medicine and Great Moments in Pharmacy, a series of commercial paintings produced by Parke, Davis & Company between 1948 and 1964. Beginning in the early 1950s, Parke-Davis delivered reproductions of the Great Moments images to physicians and pharmacies throughout the United States and Canada and funded monthly pullout facsimiles in key national magazines. The images also appeared in calendars, popular magazines, and “educational” brochures. By the mid-1960s, articles in both the popular and the medical press lauded the Great Moments for “changing the face of the American doctors office” while describing the painter, Robert Thom, as the “Norman Rockwell” of medicine. The authors’ brief analysis uses source material including popular articles about the Great Moments, existing scholarship, previously unexamined artists notes, and, ultimately, the images themselves to explain why these seemingly kitschy paintings attained such widespread acclaim. They show how the Great Moments tapped into a 1950s medical climate when doctors were thought of as powerfully independent practitioners, pharmaceutical companies begged the doctors good graces, and HMOs and health plans were nowhere to be seen. The authors conclude by suggesting that the images offer important lessons for thinking about the many pharmaceutical advertisements that confront present-day doctors, patients, and other consumers.

Structural Health and the Politics of African American Masculinity

This commentary describes ways in which notions of African American men’s “health” attained by individual choice—embedded in the notion that African American men should visit doctors or engage in fewer risky behaviors—are at times in tension with larger cultural, economic, and political notions of “health.” It argues that efforts to improve the health of Black men must take structural factors into account, and failure to do so circumvents even well-intentioned efforts to improve health outcomes. Using historical examples, the article shows how attempts to identify and intervene into what are now called social determinants of health are strengthened by addressing on-the-ground diagnostic disparities and also the structural violence and racism embedded within definitions of illness and health. And, that, as such, we need to monitor structural barriers to health that exist in institutions ostensibly set up to incarcerate or contain Black men and in institutions ostensibly set up to help them.