Authors: Jamie White, Amanda Cordova-Gomez, Raul Mejía, Janine A. Clayton
Categories: Series, Intersectionality, Interseccionalidad, Social medicine, Public health, Social determinants of health, Latin America, North America
Source: Lancet Regional Health - Americas
Authors: Jamie White, Amanda Cordova-Gomez, Raul Mejía, Janine A. Clayton
In this personal view paper, we contrast an early form of intersectionality within Latin American social medicine in the early 20th century to a form of identity-based intersectionality advanced in the USA in the latter half of the same century. The proponents of social medicine grasped and applied the principles of intersectionality from the 1930s onward, focusing on the influence of intersectional contextual factors on health. We distinguish this form of intersectionality as “interseccionalidad.” It foregrounds characteristics of oppressive systems or contexts and their effects on health. Although social medicine shares some similarities with social determinants of health, their approaches and interventions differ. Intersectionality and interseccionalidad both emphasize the role of power and oppressive systems, but systems dynamics are rarely discussed in the medical literature; therefore, we discuss systems change within healthcare and the health innovation ecosystem by using an established systems theoretic approach. Lastly, we give examples of and call for further development of ways to integrate the best of intersectionality and interseccionalidad in research and innovation.
We compare differences in historically distinct intersectional approaches to health and healthcare in North America (global north countries–United States and Canada) and Latin America to highlight the usefulness of integrating both approaches. To differentiate between the perspectives of North American and Latin American authors, we use the English term “intersectionality” for the former and the Spanish term “interseccionalidad” for the latter. Although the Spanish-language literature also uses the term “interseccionalidad” for the translation of the North American form of intersectionality, we seek to make important distinctions between these two forms of intersectionality for the English-language literature. Ultimately, we focus on what the verb form—to intersect—can accomplish over what the nominalized form—intersectionality—has or has not accomplished. Intersectionality is not and never will be a fait accompli. As times and situations change, so too will intersecting factors change. Thus, an approach based on asking “what is intersecting?” seeks not to examine a predetermined set of factors but entails determining the specific factors that shape a given situation for a given person(s). Optimal healthcare and health innovation can be realized only when both intersecting contextual systems and the patient’s intersecting identities are considered.
Emerging from the women’s movement of the 1960s, black feminists in the 1970s, including those in the Combahee River Collective, continued to struggle against racial, sexual, and class oppression.^1^ By fighting on those interlocking fronts simultaneously—none of which privileged them—they felt that they were fighting not just for themselves but for underrepresented people worldwide.^1^ In 1989, legal scholar Kimberlé Crenshaw coined the term “intersectionality” to explain how interlocking systems of power and oppression in the US legal system discriminated against black women in ways that it did not discriminate against either white women or black men.2, 3, 4 Intersectionality as a topic of study further developed primarily in the womb of gender studies rather than in racial or class studies (sociology) or studies of identity (psychology).^5^ In 2015, Collins provided the following consensus “intersectionality references the critical insight that race, class, gender, sexuality, ethnicity, nation, ability, and age operate not as unitary, mutually exclusive entities, but as reciprocally constructing phenomena that in turn shape complex social inequalities.”^5^ Subsequently, the purview of intersectionality expanded rapidly; scholars used it as a concept, paradigm, heuristic, methodology, or theory^5^ in various interpretive communities, healthcare being one of them. Although Crenshaw originally called out interlocking oppressive systems, the field swerved toward discussing intersecting identities. Feminist theorists, however, point out problems with an identity-based approach to intersectionality.^4^^,^^5^ Although we cannot review those problems here, we do ultimately address them, since patients have a personal identity constructed from social categories and can be affected by oppressive systems.
To illustrate the difficulty of making cross-cultural comparisons of intersectionality based on identity characteristics, consider the differences in what it means to be Black, Latino, or a woman across geographies and cultures.^6^ Millions more enslaved Africans were brought to South America and the Caribbean than to North America, and many more indigenous people were also de facto enslaved via practices of encomienda (a system where Spanish conquistadors could extract labor and tribute from the Indigenous people in “exchange” for protection and Christian education) and repartimiento (the successor to forced Indigenous labor after the encomienda system was deemed abusive).^7^ Correspondingly, what it means to be Latino differs in Latin and North America. Because the Spanish and Portuguese conquered much of Latin America and set themselves up as the ones in power, having direct or even mixed European heritage can imply higher status, even today, where there are still vestiges of colonialism, with Indigenous and Afro-descendants being the marginalized groups in some but not all Latin American countries. In the early 20th century, with considerable immigration to Latin America from Europe as well as internal migration from the rural areas to the cities, identity became even more nuanced and politicized.^8^ Presently, some authors argue that generalized categories, such as “mestizo” oversimplify identity by assuming homogeneity, making it not only difficult to recognize and address individual and community expressions and needs, but it also perpetuates discrimination and undermines agency.^9^ As discussed by Zajdel and colleagues, the importance of race and ethnicity as a demographic social determinant is less emphasized in Latin America, with socioeconomic status considered to be the principal determinant of inequity.^10^
Similarly, the geographic area comprising Latin America has been defined differently by different authors. In addition to South America, some researchers include Mexico and other meso-American countries in Latin America, and others include the islands of the Caribbean. In Latin America, there is also a larger indigenous population (40 million people, compared to 9.7 million in the US and 1.8 million in Canada) that is highly diverse both within and among nations.^11^^,^^12^ The colonial social hierarchy still exists in certain areas. Compared with the British and French conquest of North America, in countries colonized by the Spanish and Portuguese, there was more interbreeding with indigenous populations. Such offspring (mestizos) are a racial category that is not recognized in the United States. Similarly, offspring of white and black parents also form another distinct category (mulato, mixed race, brown, or pardo) and are subject to discrimination similar to that in the north. Thus, the categories of ethno-racial status are more nuanced in Latin America than in North America but are just as influential in social inequities.
To understand the medical contexts in which the different approaches to intersectionality and interseccionalidad emerged between North and Latin America, we first consider differences in the way the health of populations has been defined and studied in each region. Although intersectionality emerged from women’s studies and jurisprudence, its interpretation by medical fields (research and healthcare) in North America is grounded in the historical development of the field of public health.
In the 17th and 18th centuries, epidemics such as the plague, cholera, and smallpox ravaged many parts of the world. Because those epidemics did not kill everyone affected, some physicians thought that different people were simply more susceptible to disease. That intuition was confirmed in 1854 by John Snow, who systematically identified the first pattern of contagion of cholera in London. The field of epidemiology was born along with better understanding of the importance of good sanitation.^13^^,^^14^
In the United States, early efforts to treat and control such epidemics, initially among merchant seamen, resulted in the creation of the US Public Health Service, where epidemiologists continued to study structural relationships, such as between a given infectious agent or toxin and a physiological response.^15^ Because the field of public health began by researching epidemics, its primary unit of analysis is the population—a sum of individuals classified into groups based on characteristics such as sex, age, education, income, race, or ethnicity.^16^ Although characteristics such as race/ethnicity, sex/gender, and age are now standardly analyzed in biomedical research, it is still relatively rare to find studies that consider combinations of those characteristics and/or intersecting contexts on outcomes. However, the recent COVID-19 pandemic clearly revealed intersectional differences.^17^^,^^18^
The term “social medicine” was developed in 1848 simultaneously in France and Germany.^19^ Importantly, social medicine is not equivalent to socialized medicine. “Socialized medicine” refers to a government-based structure of funding for care, whereas “social medicine” refers to the way health and disease are related to the social structures, especially power structures, of society. The adoption of social medicine (or saúde coletiva “collective health” in Brazil) approaches came to Latin American countries at different times and to different extents during the early part of the 20th century. A focus on social medicine (or collective health) spread through Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, and Mexico to the greatest extent and through other countries to a lesser extent. Notable practitioners include Ramón Carrillo in Argentina, Mario Testa in Brazil, and students of Rudolf Virchow, especially Salvador Allende in Chile.^19^
The foundations of social medicine are grounded in observations that social circumstances, such as poverty, political disempowerment, and poor working conditions, among others, create conditions for ill health. This approach emerged from observations by physicians that if such contextual conditions remained the same, treatments were less effective. Poor sanitation, poverty, overwork, and other forms of oppression not only fostered sickness but also hindered recovery. Social medicine physicians sought not only to treat their patients but more importantly to “treat” society by engaging in social activism—often at great personal risk—to counteract the effects of social policies, the occupational and environmental causes of illness, the mental health effects of political trauma, and the impact of gender.^20^
In contrast to public health where the whole is viewed as the sum of the parts, social medicine considers the whole, whether population or social institution, to transcend the sum of the parts.^16^ Whereas public health considers health and disease as binaries, social medicine sees a health-disease continuum grounded in social context. It foregrounds the social, economic, and environmental systems that foster illness or contribute to people’s collective ability to be healthy. A social medicine approach emphasizes that individual and group characteristics need to be analyzed not as isolated variables but as variables shaped by the systems within social contexts.^16^ For example, a patriarchal context determines what it means to be a woman differently than does a context of patriarchy implies power differential, poverty implies economic differential. Those two contexts can overlap to disadvantage some people (e.g., poor women) more than others, regardless of the individual’s sense of identity. A general comparison of public health and social medicine along several dimensions is shown in Table 1.Table 1Comparison of the principles of public health and social medicine.DimensionPublic HealthSocial MedicineFundamental assumptionsSociety is the sum of the individuals in the populationSociety is a totality that includes contradictions; hence, the characteristics of the society itself must be studiedUnit of analysisIndividual and below (e.g., molecular, genetic)Social (group), e.g., economic group (owner vs. workers), ecological (location: urban vs. rural), historical; Interpersonal and above (e.g., community, society)Basis of diseaseBiologicalSocial conditionsDichotomy between health and illnessHealth-illness as a continuum and processCausalityMonocausal explanation of disease (e.g., genetics, pathogens)Multiple causes, contextual, even economic conditionsIntervention focusProvide treatment to individual for diagnosed health conditionChange the underlying (unbalanced) system(s) and structural drivers of health-illnessMethodology (ies)Primarily quantitative in medicine; mixed methods in social science, but mostly siloed with few transdisciplinary approachesMixed-method, multi-level, triangulation of data between individual and group/social; more research conducted in association with labor unions, communities, etc. Innovation: group interviewPrimary tension(s)Race and gender; class is secondaryClass (owner vs. worker); there was more intermixing of ethnicities in some Latin American countries, but nevertheless, with colonization, a caste system was formally instituted by Spain and Portugal, with those from Europe (or European descendent) at the top and Afrodescendents at the bottom of the hierarchy.Internal conundrumBy putting responsibility on the individual, it exempts the larger systems (whether civil, governmental, or corporate) from having to take responsibility for their part of the problem, because individuals have little leverage to make a difference to the system.By focusing on context, it puts those who are responsible for it or those in power (e.g., owner, state) in opposition to those affected by that context (workers). When the state has rectified harmful situations, people’s health improved (as in Chile); when it ignored it (as in Mexico), people’s health did not improve, and they protested or staged union strikes.Medicine and healthcare systems“Modern medicine” using public health/epidemiology as a proxy with a focus on innovation, medical specialties, advancement, commercialization, and R&D ecosystemsMedicine using population and societal outcomes as a proxy with a focus on the built and social environments, whole person health, class, and employment structuresaaThe social medicine approach has integrated modern medicine to a greater extent than modern medicine has integrated social medicine, although there is an increasing trend toward recognizing the social determinants of health and whole-person approaches, which are integrative within a healthcare environment but not yet within the political sphere.Sources: Adapted from Waitzkin et al., 2001, 2020; Breihl 2002.^17^^,^^21^^,^^22^
The methodology of social medicine research often differs from that of public health research by allowing the intersections of systems and power structures to be determined by the research question and population(s) studied, particularly in light of the diversity among Latin American subcultures. Whereas public health research categorizes people a priori (for example, by race, sex, age, socioeconomic status based on income, disability, and disease status), in social medicine research, the definition of the collective is not necessarily given a priori but is defined according to the problem being analyzed.^16^ In social medicine, many similar categories nevertheless emerge across studies, including “social reproduction, social class, economic production, culture, ethnicity, and gender, among others. It is through these categories that individual specificities, such as sex, age, education, income, or race, find their explanatory determination. For example, if the specific economic, social, political, and ideological characteristics that define being a woman or man in relation to the studied problem in a particular society and historical moment are not made explicit, the determinants underlying sex classification are being overlooked.”^16^ Fig. 1 symbolically illustrates how context defines the contours of the “object” of study, using a figure/ground visual metaphor.Fig. 1Cup and faces, figure and ground. This well-known visual metaphor is used here to illustrate that in intersectional research and applications, it is important to see and understand both the characteristics of the topic of study (the cup) and the context that simultaneously defines the borders of the topic (the faces). It is in the interaction of the two (i.e., the boundary that separates the black and white regions) that determines, in our context, intersecting identities (represented by the cup) and intersecting contexts (represented by the faces).
Although the North American form of intersectionality emerged in late 20th century black feminism and jurisprudence, the Latin American form, which we call “interseccionalidad,” originated in social medicine in the early 20th century. Latin American social medicine was originally a critique of the prevailing assumption that economic growth would automatically lead to improved health. This was not the case in most Latin American countries.^16^^,^^23^ Although they did not use the term “interseccionalidad,” they clearly grasped and applied the principles of intersectionality. For example, the early proponents of social medicine had “a vision of multiple social structures and processes impinging on the individual. Disease was not the straightforward outcome of an infectious agent or pathophysiological disturbance. Instead, a variety of problems—including malnutrition, economic insecurity, occupational risks, bad housing, and lack of political power—created an underlying predisposition to disease and death [emphasis added].”^24^
The practitioners of social medicine clearly recognized the intersecting power structures operating in society. As with intersectionality, interseccionalidad involves an intersection of oppressive systems, but they are identified, not as abstract -isms, such as racism, sexism, and classism, but more concretely as labor exploitation, working conditions, work processes, and environment/living conditions (poverty, overcrowding), the interactions of which foster the conditions for disease to occur, propagate, or persist, whether biological (infections, epidemics) or chronic (workplace injuries and conditions, such as pain, lung disease, or even current lifestyle diseases).
Social medicine challenges the societal values that preserve the structures of oppression. However, the medical profession cannot change society or its values on its own, especially by remaining grounded in the economic system(s) that preserve those same structures of oppression. As long as commerce takes priority over health as a societal value, the hopes and ideals underlying intersectionality/interseccionalidad will likely remain elusive.^19^
Much of the research that was done by social medicine practitioners was done in coordination with labor unions, women’s groups, Indigenous coalitions, and community organizations in order to show connections between working conditions, living conditions, and illness. However, multivariate models, such as logistic regression, using disease as a dichotomized dependent variable (present/absent), were criticized for not being able to account for the dynamics of the health-disease process.^24^ Thus, new approaches to both data collection methods and statistics were developed in the 1970s. For example, the collective interview and a way to triangulate individual-level data with group-level data were developed.^16^ Unfortunately, much of that important methodological literature has not been translated into English.
A research approach grounded in social medicine focuses on many specific aspects of life and work that influence health. For example, in a three-year study of female workers in Ecuador, titled Mujer, Trabajo y Salud (Women, Work and Health), the authors used both qualitative and quantitative methods to study the health of office workers, garment factory workers, and peasants.^21^ They determined the effects of numerous work and domestic processes on the women’s health. Destructive work processes included, for example, the frustrating, monotonous, or routine nature of the work, lack of recognition, insufficient training opportunities, poor organization of work processes with task duplication, uncomfortable and inadequate postures, ergonomically inadequate furniture and equipment, inadequate ventilation and lighting conditions, noise pollution, and overcrowding.^21^ Destructive domestic processes included the patriarchal structure of domestic life exemplified by unequal distribution of household responsibilities, such as cleaning and cooking, where male support is less than 10%.^21^ Health outcomes were investigated along many dimensions, including infections, chronic diseases, surgical interventions, standard biometrics, audiometry, hemoglobin, visual capacity, and complete examination of the spine.^21^ The results show the combined negative effects of work and domestic contexts on the health of Ecuadorian women, but more importantly, this example is intended to show the different approach taken by social medicine to study intersectional effects not of social identity factors but of multiple contextual circumstances (work-related and domestic) on the whole health of workers.
In light of renewed interest in social determinants of health (SDOH), one could ask whether social medicine is the same as SDOH. Although there are similarities, these two approaches are grounded in different fundamental principles and methods. Nevertheless, over time, boundaries soften, and distinctions have become blurred. Indeed, ecology^22^ and computing (e.g., network analysis as a way to model relationships^25^) have influenced the biomedical sciences toward intersectional approaches, and social medicine approaches are being integrated into “whole health” proposals. Conversely, public health approaches have also been adopted in Latin America.^25^
Key differences between SDOH and social medicine include how the intersecting systems are determined and the nature of the response. With SDOH, the systems studied are often, but not always, identified a priori. For example, the Centers for Disease Control and Prevention (CDC) lists principal SDOH as economic stability, education access and quality, health care access and quality, neighbourhood and built environment, and social and community context.^26^ The World Health Organization cites the inequitable distribution of power, money, and resources—the structural drivers of those conditions of daily life.^27^ In contrast, social medicine identifies the operative systems that form the “ground” in a figure-ground relationship (Fig. 1) situationally, as appropriate to the patient group, disease, or research question.
The second difference between SDOH and social medicine pertains to how issues that have been identified are then addressed. SDOH tends to follow the medical approach of treating the individual, whereas social medicine calls for collective actions as well. Because social medicine defines the population as a whole as having properties that are greater than the sum of the individuals who comprise it, the population as a whole needs to address the issues of those who comprise it. Thus, health issues that affect a community or society must be addressed by that community or society, not just by the doctors and patients within it. In a medicalized society, treatments are given to patients; in a social medicine framework, it is thought that “treatments” also need to be applied by the population to itself. An example of a population healing itself is the work of the Abuelas de Plaza de Mayo (Grandmothers of Plaza de Mayo), an Argentine human-rights organization that took collective action locally, nationally, and internationally to restore the children disappeared (kidnapped) by the military dictatorship to their families.^28^ Hence, social medicine can take the form of altering not just personal behavior but also changing policies, practices, laws, and especially values.
To illustrate, SDOH research might determine that air pollution combined with climate warming corresponds to higher levels of childhood asthma in a given locale. A typical medical treatment might be to distribute inhalers or asthma medication to those children. In this scenario, although systems-level influences are studied, the solution is not a systems-level solution. A social medicine approach would emphasize eliminating the sources of air pollution (e.g., by changing the laws at the societal or community level) and addressing climate change across multiple intersecting systems simultaneously so that everyone in that locale would be healthier. Unfortunately, SDOH can underemphasize the forces of oppression and sources of injustice thereby obfuscating those responsible for creating health inequities.^24^
To show how societal systems intersect, consider the following people living in food deserts are less likely to get good nutrition, which increases their risk of heart disease, diabetes, obesity, and early mortality relative to people with access to healthy foods.^26^^,^^27^ A public health approach might give individuals vouchers for healthy food or build grocery stores in food deserts. In contrast, a social medicine approach recognizes that 1) putting an organic grocery store in an economically depressed area might not remedy the situation if the people in such a community could not afford such food, don’t have the time to prepare it, or if the food is not culturally relevant/sensitive, and 2) systems of food security and availability intersect with economic systems that control wages. Thus, it is most effective to address multiple leverage points within multiple systems simultaneously to ameliorate the health issues stemming from both wage and food insecurity (Box 1).^29^Box 1Understanding leverage points within systems.The health innovation ecosystem and healthcare systems are complex, involve unpredictable feedback loops, interact with other systems, and require multi-system coordinated change.^28^ However, the intersections of large-scale systems and actions required to change systems are rarely discussed in the medical literature.Systems theorist Donella Meadows identified key leverage points that can alter systems a little (e.g., fines or subsidies) or a lot (e.g., self-organization). The most-effective leverage points change the context or mindset within which the system operates, thereby forcing the system to adapt.^28^Leverage points are places in a system where a small change could lead to a large shift in behavior of the system.^28^ We discuss important leverage points in increasing order of leverage; that is, the latter ones produce greater system change. We illustrate them using examples from the other papers in this series or the health innovation ecosystem.Tweaking parameters within the system. Example: the amount of toxicity allowed in the risk-to-benefit calculations for products or the amount given to an industry as a tax benefit.Stocks and flows. To conceptualize stocks and flows of a system, think of a opening the spigot increases water flow and opening the drain decreases the stock of water in the tub. Example: setting a quota or hiring more people from underrepresented groups into the biomedical workforce increases their percentages (increased flow), but if the institutional culture does not change to enable them to feel included, many will leave (decreased stock).Delays are built into a system to ensure proper timing, or they can occur as a consequence of other system changes. Examples: a probationary period for a new hire or delayed approval of a new drug to determine potential long-term adverse effects.Information flow—who has access to what information. Lack of information flow is a common cause of system malfunction—as when one division or physician is unaware of what others are doing. Examples: improve data collection, monitor cases of discrimination.Rules of a system are often codified in policies. Systems can also have implicit or unwritten rules (e.g., redlining). Examples: career-progression policies, performance reviews, work-life balance policies, regulatory policies.Self-organization—the power to add, change, or evolve the system. This is a powerful leverage point particularly when this power is distributed to those in the organization or system. Examples: change institutional norms and culture, such as by instituting a culture of mentorship/sponsorship and a culture of open communication. In the health innovation ecosystem, products for women were not being funded by venture capitalists, so women self-organized to form their own venture capital companies to support women entrepreneurs.Explicit and implicit goals of the system. Explicit goals are those stated publicly in strategic plans or research agendas/roadmaps, such as “to enable more people to be in control of their health.” Implicit goals (of the same system) are internal to the organization or parts of the system, such as to increase revenue each year or “enhance shareholder value.” It is important to understand when a system has goals that are at cross-purposes (e.g., “hire the best people” [explicit] and “cut personnel costs” [implicit]).Changing the mindset, paradigm, or culture. Cultural values and assumptions shape the structures of the systems within them. Examples: general (societal) education campaigns to reduce stigma and discrimination or patient advocacy campaigns to increase funding for research and innovation.Most importantly, it is necessary to continually question one’s assumptions about paradigms and systems, to attend to what is important, not just what is quantifiable; locate responsibility in the system; and coordinate different leverage points to maximize and sustain changes in the system.^28^ These high-level leverage points comprise the kinds of contextual shifts that social medicine seeks to implement.
Systemic forces are what the originators of intersectionality intended to address. However, when intersections of social identities are emphasized, such intentions can become diluted. It is one thing to bandage one’s wounds and point to a bully as their cause; it is something else entirely to rehabilitate or disempower the bully, as that requires others—not just the one bullied—to hold the bully to account or change the mindset of the bully and have them willingly participate in bandaging the wound. The issue is amplified when the bully is an institution or system.
Integrating intersectionality and interseccionalidad is not an additive process; rather, it involves a gestalt, akin to seeing the cup and the two faces—figure and ground—simultaneously (Fig. 1), whereby one sees the identity intersections (the cup) as well as the contextual intersections (the faces), as well as the intersections between them (the contours of the interface between cup and faces). An individual’s lived experience of, say, the intersections of racism, sexism, and ageism would need to be contextualized within their lifeworld, as the specific ways in which oppressive systems intersect to create that experience—whether it involves the healthcare system, the financial system, the educational system, the legal system, or local customs and practices. Fig. 2 illustrates, metaphorically, the combination of intersectionality and interseccionalidad in relation to health equity.Fig. 2Depiction of the health ecosystem with different systems that individuals often have to navigate in order to have their health needs met. The fruit symbolizes an unmet health need and once held by an individual symbolizes their health need being met. **(A) Health ** In this picture, neither the black older gentlemen (Carlos), the middle-aged Latina women (Lucia), nor the white gentlemen in the wheelchair (Bobby) have their health needs met. None of them have the tools or resources to attain their unmet health needs (any fruit) for a variety of reasons within different systems, including economic (high price at the fruit stand), environmental (snake or height of the trees), structural (stone being a barrier to fruit tree), or geographic (location of the fruit). **(B) Health equity with an intersectionality ** Carlos, Bobby, and Lucia are all provided with specific tools tailored to their needs in order to have their health needs met (attain a fruit). Health inequity is solved with an intersectionality lens by the solution utilized being tailored to the individual. For example, Carlos received a stool so he could have his health need met (reach an apple). Lucia received a ladder in order to meet her health need (an apple); due to her height she would not be able to use the stool Carl leveraged to attain her health need. Bobby was given a long hand grip device to attain his unmet health need (an apple) because, due to being wheelchair-bound, he would not be able to use Carl’s stool or Lucia’s ladder. It is also important to note that all of these individuals went after the same type of fruit (the apple tree) symbolizing solutions for unmet health needs or solving for health inequity in the US and Canada often do not take a systems approach (or solve for the system), but instead are tailored to the individual(s) experiencing a health inequity. In addition, within this model (intersectionality lens) there is often a misconception and an assumption that everyone has the same unmet health needs or that health needs are generalizable, a common element of public health. **(C) Health equity with an interseccionalidad ** In this picture, all the systems (trees and fruit stand) were augmented allowing for easier access to Lucia, Bobby, and Carlos to have their unmet health needs met. The apple tree was augmented to provide stairs up the tree for Lucia to climb so that she can have her unmet need met. Though another barrier (snake) was still present, she was still able to attain her health need (an apple). This system’s solution (ladder) could have been leveraged by Carlos as well, if he had a similar unmet health need (an apple). Carlos instead had a different unmet health need (a plantain) and used a systems-based solution (the machete) as a tool to attain his unmet health need. An unobstructed pathway was developed to provide easier access to another system within the health ecosystem (the mango tree). These systems-based solutions (the stone boulder removal and path development) removed a barrier and made it easier for Bobby to attain his unmet health need (a mango). This new path could also be leveraged by both Carlos and Lucia as well if they had a similar unmet health need (mango). Lastly, it is important to note that with an interseccionalidad lens all known systems that impede on health are augmented, hence the change in the price of fruit at the stand, even without someone actually leveraging it. **(D) Best of both ** In this picture, both individual-based (intersectionality lens) and systems-based (interseccionalidad) solutions are leveraged to attain the unmet health needs (different fruits) of Bobby, Carlos, and Lucia. In some circumstances, individually tailored solutions are necessary or better, as depicted with Bobby being able to get several unmet health needs (apples) by using the long-hand grip device. He, unfortunately, would not be able to use the system solution (steps on the tree) and so needed his individual-based solution (the long-hand grip device). This individual-based solution actually served him better because he is also able to attain his unmet health need (the fruit) and avoid another barrier (the snake) more safely than if he used the systems-based solution (the ladder). Having both options is advantageous for many people to be able to attain their unmet health needs. Another example of this can be seen, where the systems-based solution (unobstructed pathway) and individual-based solution (ladder) are both leveraged by Lucia to obtain multiple mangos. In addition, being able to leverage both a systems-based solution and an individually based solution can enhance one’s ability to meet health needs. This is the case for Carlos: he can leverage his individually based solution (stool) to attain better health, symbolized by retrieving more plantains than he could with just a systems-based solution (machete). Lastly, in this picture, notice the young lady (Lisa) is bringing fruit (grapes) to Carlos, Lucia, and Bobby. Lisa is symbolic of the next generation, which can bring new and different solutions for unmet health needs to the community (Carlos, Lucia, and Bobby). In the best of both worlds, the community (group of individuals) can come together to leverage both systems-based and individually-based solutions to have more unmet health needs met collectively (illustrated by multiple fruits for all community members—Carlos, Lucia, and Bobby) and potentially share or provide for the needs of other community members’ unmet health needs.
Research that encompasses identity-based intersectionality and context-based interseccionalidad can be challenging because it calls for an integrative approach. Most statistical methods, however, use a reductionistic approach to isolate specific factors or influences.^30^ Couto and colleagues recognized the need to integrate intersectional approaches and methods.^31^ They reviewed the theoretical-methodological literature in the field of public health/collective health and noted that gender, race, and class, are often analyzed separately from SDOH, but when they are superposed, different patterns of risk and resilience emerge.^31^ When both identity characteristics and contextual/systemic factors are explored simultaneously, and different approaches for designing studies and collecting and analyzing data are developed, new ways of understanding the health-disease process can emerge.
Shannon and colleagues used a case study synthesis method drawing on examples of racism from different cultures to understand how racism, xenophobia, and discrimination are shaped by systems of power/oppression (e.g., caste, religion, and immigration status) and together affect health and well-being.^32^ Their analysis explored details that would have been lost if only a quantitative approach had been used. Thus, methods to understand a population as a whole and to be able to understand the forces it exerts on individuals—different individuals at different times—need to be refined. Mixed methods (qualitative and quantitative, analytic and synthetic) as used in the behavioral sciences and cultural anthropology or techniques modeled on those used by linguists to analyze conversational power dynamics can be adapted to study the interactions of systems of different levels and scales, such as individuals (patients) and the social, economic, or environmental systems in which they live.^33^ Data-layering approaches that combine interactive and/or expansive ways to visualize data can be used to convey complex relationships within/between individuals and populations, as well as for lifespan and historical approaches. As people age and as societal values change, power dynamics also change in complex, culturally specific ways, for all people, individually and in relation to one another and between themselves and society as a whole.
The US National Academies of Science, Engineering, and Medicine (NASEM) recently encouraged researchers to address social, economic, and environmental factors and systems that contribute to health inequities. Their report, Communities in Action: Pathways to Health Equity,^33^ defines the main SDOH as the conditions in the environments in which people live, learn, work, play, worship, and age. These factors affect a range of health, functioning, and quality-of-life outcomes and risks involving systems of education, employment (income and wealth), health systems and services, housing, the physical environment, public safety, the social environment, and transportation.^34^ Although the report echoes statements in the social medicine literature and calls for widespread system change, its actual recommendations are generally limited to community activism rather than society-level mindset change. Communities acting in isolation can do good, but they may still find themselves restricted by higher-level policies, regulations, and societal values. Calling for broad social changes but implementing only limited interventions, however, can perpetuate the oppressive systems that cement intersectional inequities.^19^
Health innovation has been defined as the creation or implementation of new or better solutions (i.e., product, process, policy, service, or technology) that improve patient health outcomes. To attain the best of both worlds in healthcare innovation, the scientific and healthcare workforces could be more effective if trained in a transdisciplinary manner and in systems thinking as a conceptual framework. This will allow innovators to integrate multiple dimensions and discern patterns, contexts, and interrelationships, not only among fields but also for each patient. Systems thinking can help us retrospectively understand why well-intentioned innovations or treatments failed and help us adopt better systemic solutions.
The 2023 NASEM report, Toward Equitable Innovation in Health and Medicine: A Framework, emphasized the need to promote intersectional approaches in science, technology, and innovation, not only in terms of who gets to create such innovations but also who benefits from them.^35^ Except for specific instances in which ideals have shaped policies and procedures, such as mandating protection of research subjects, clinical trial inclusion policies, health insurance access, protecting against genetic discrimination, and developing new uses for orphan drugs, most health innovations benefit very few people worldwide. Ultimately, the goal, according to the NASEM report, is to engage leverage points that influence the ways societies govern science, technology, and innovation in healthcare and broaden participation in the health innovation ecosystem.^35^
By integrating the principles of both intersectionality and interseccionalidad into the healthcare, research, and innovation ecosystems as well as our societies, it can be possible to achieve better outcomes for all. Because needs, resources, and culturally acceptable solutions differ by locale, a “best of both worlds” approach strives to customize specific interventions at the appropriate scale, while also coordinating efforts at greater (national, global) scales, to better understand the system dynamics.^29^ A solution developed for one type of community (or society) could also be applicable to others, with appropriate adaptations based on each community’s needs. For example, the Women’s Health Innovation Opportunity Map outlines 50 equitable, high-return opportunities to advance global innovation for women’s health—in healthcare, research, industry, education, academia, and government.^36^ It was developed by the Innovation Equity Forum, a partnership with over 250 stakeholders across diverse sectors (academia, government, industry, and community partners) and demographics from over 50 countries, including countries in North and Latin America. The Women’s Health Innovation Opportunity Map 2023 recommends partnership-building between patient advocacy groups, funders, and publishers, for example, and between community organizations, social justice organizations, local elected officials, policy makers, and even the media to create conditions in the health innovation ecosystem in which the distribution of power and resources is balanced. This important new resource offers a way forward for new research and funding opportunities, consolidated advocacy efforts, and increased global action and investments in women’s health, and it highlights the importance of taking intersectional approaches (Fig. 3).^36^Fig. 3Adapt****ed figure from the women’s health innovation opportunity map. The Opportunity Map has three key components. First, it lays out ten broad topics of women’s health innovation with unique challenges, needs, and objectives. For each topic, leading opportunities were identified based on their potential for impact, readiness to scale, innovation feasibility, focus on women’s unmet health needs, and ability to improve health equity. Finally, specific solution strategies articulate actionable ways to realize each opportunity and create impact within the next 15 years. As such, this Opportunity Map provides a guide that stakeholders across the women’s health research and development ecosystem—from researchers to entrepreneurs, investors, government bodies, biopharmaceutical companies, civil society, and more—can use to advance high-impact investments and initiatives to improve women’s health. This figure features the opportunities identified specifically regarding social and structural determinants of women’s health (in accordance with intersectionality and interseccionalidad) and training and careers for the healthcare workforce. Other opportunities not shown here include those for data and modeling, research design and methodologies, regulatory and science policy, innovation introduction, communicable diseases, noncommunicable and chronic conditions, female-specific conditions and partnerships. These opportunities were identified by over 250 experts from 50 countries at virtual and in-person meetings of the Innovation Equity Forum. The full report can be accessed https://orwh.od.nih.gov/sites/orwh/files/docs/womens-health-rnd-opportunity-map_2023_508.pdf.
By implementing both approaches to healthcare—intersectionality and interseccionalidad—the healthcare workforce could create a vibrant ecosystem that confronts the values, mindsets, and paradigms that perpetuate the power dynamics and power structures that currently entrench the many persistent inequities in health outcomes within countries and across nations, in particular between North and Latin America. In addition, more appropriate methodologies by which to study the influence of intersectional influences on health can be developed using transdisciplinary approaches that engage researchers, clinicians, engineers, economists, payors, data scientists, patient advocates, policymakers, funders, and entrepreneurs. For instance, quantum computing methodologies being leveraged to study the health-disease continuum more effectively. Lastly, by working collaboratively and collectively to bring people from different sectors, systems, and nations together, it might be possible to manifest this vision in this complex and interconnected, albeit unbalanced, world.
JW participated in the writing of the manuscript and has reviewed and approved the final version.
ACG participated in the writing of the manuscript and has reviewed and approved the final version.
RM participated in the writing of the manuscript and has reviewed and approved the final version.
JAC participated in the writing of the manuscript and has reviewed and approved the final version.
Jamie White is on the advisory board for the Women’s Health Innovation Series, a member of the Medtech Color Collaborative Community and Founder and CEO of iHS Strategies, LLC. Janine Clayton is a member of the Board of Directors for the American Association for the Advancement of Science and a member of the Medtech Color Collaborative Community. The other authors declare no conflicts of interest.