Injustice anywhere is still injustice everywhere.
Structural violence, as defined by Dr. Paul E. Farmer, is “one way of describing social arrangements that put individuals and populations in harm’s way.” The health impacts associated with structural violence prevent vulnerable populations from gaining access to basic needs. This is due to injustices embedded within institutions and social structures that exist in today’s society.
These inequalities affect immigrants, minorities, migrants, the poor, those who do not speak English as their primary language, the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community and many other marginalized groups. For those individuals who carry multiple of these intersecting and marginalized identities, they become structurally vulnerable and are more likely than others to experience these inequalities.
According to the World Health Organization (WHO), universal health coverage means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. In the United States, health care is not accessible by the entire population. There are a few subsets of the American population whose members are universally covered. Military personnel and their dependents may access Tricare to receive health care services; even so, there are veterans that remain either underinsured or uninsured. There are millions of Americans today who, even after the implementation of the Affordable Care Act, have no health care insurance.
Even those who do have insurance are not necessarily able to access health care services. Patients with employer plan benefits may see deductibles as high as $1500 per individual. Even if individuals manage to pay their deductibles, finding a primary care physician (PCP) may be challenging. In California’s Inland Empire — a geographic area consisting of Riverside and San Bernandino Counties — alone, there are approximately 35 PCPs per 100,000 patients, well below the recommended ratio of 60 to 80 PCPs per 100,000 patients as noted in the 8th Report from the Council on Graduate Medical Education.
Picture this scenario: You wake up at 4 a.m., eat breakfast, say goodbye to your family and leave for work. You clock in at work at 5 a.m. with the rest of your co-workers and make your way to the fields. You carry with you all the essentials: hat, sunglasses, long-sleeved shirt, water and tree clippers. You work quickly and laboriously to pick as much fruit as possible before sunrise. Why sunrise? You want to beat the sun because, in a matter of minutes, temperatures can skyrocket to well over 100 degrees. The thought of heat stroke sits at the back of your mind, but you continue to work.
Aside from the obvious element of heat, another element — the wind — can easily betray you. The wind carries dust from a nearby sea, which has been drying up and, as a consequence, has left behind dead fish and particulate matter. You do your best to protect yourself from the dust but still feel its effects. Day after day, you punch in despite the occupational hazards. Afterwards, you go home following a 16-hour shift and lie down. You worry about paying rent, providing for your family and sending money back home. You feel the weight of the world on your shoulders. Or your back. Or your knees.
Now let’s suppose that you succumb to physical pain and injury or unmanaged diabetes. What do you do? Do you risk taking a day off work without pay and spend your precious hard-earned money on a doctor’s visit? Or, do you decide to take some time off and go to the doctor whose office takes approximately 30 minutes to reach by car or two to three hours by bus? Do you risk making that trip knowing that at any point you might get stopped by border patrol and be deported?
If you go to the doctor, you may find it difficult to navigate the system — and not for lack of trying. The staff might not speak your language. You fear being turned away or, even worse, getting deported because you do not have health insurance. By now, half the day has gone by, and you wonder if you made the right choice. You are frustrated with the lack of translators who speak your language. You fear the risk of deportation. You continue this cycle day in and day out, deciding between your health and the safety of your family.
This scenario, which at first glance might appear to be that of a developing country, is unfolding in our own backyard. This scenario is a generalization of the reality that Latino migrant farmworkers in California’s Eastern Coachella Valley (ECV) face every day. In the last four years, Dr. Ann Cheney at the University of California Riverside School of Medicine has conducted research that has shed light on the health care disparities present in and needs of the ECV. Inspired by Dr. Cheney’s research, a group of motivated first-year medical students led by Armando Navarro and Daniel Gehlbach sought to combat the structural violence that this population of Latinos experience because of their ethnicity, citizenship and geography by creating Global Health @ Home (GH@H).
GH@H is a consortium of universities, colleges and community partners across the Inland Empire that provides care to underserved and vulnerable populations in rural communities. GH@H also serves as an opportunity for the next generation of health care professionals to train, learn and practice cultural humility and structural competence. The multidisciplinary team is composed of medical students from the UC Riverside School of Medicine, Physician Assistant students from Cal Baptist University, and undergraduate translators from both UC Riverside and Cal Baptist University. Our goal is to not only treat underserved patients, but to learn to interact with different health care professionals to bridge gaps in the delivery of care.
Our team began planning outreach efforts in early January 2019 and implemented a series of mobile clinics in the ECV in the spring of this year. To date, we have conducted three clinics and provided free medical care to 50 patients. This number is impressive, especially given the community’s fear that doctors and clinics evoke. By working alongside and in collaboration with a team of promotoras — trusted members of the community — we are slowly but surely developing trusting relationships within this marginalized community. In the upcoming months we are vigorously planning future clinics, identifying community partners and creating a means to provide health care that this underserved community needs and fully deserves.
To other medical students who wish to address the barriers to care, look no further than your own classmates! GH@H’s members were recruited due to their involvement in overlapping student interest groups such as Organized Medicine, Latino Medical Student Association and Global Health interest groups. Find a group of like minded individuals who are passionate about eliminating health disparities and begin a conversation. Combatting the barriers to health may take on different forms and not necessarily that of a clinic. You might find yourself promoting civic engagement or hosting nutrition classes. Whatever the case may be, be sure to set your goals and meet with your school’s administration to find support.
Contributing Writer
University of California, Riverside School of Medicine
Daniel Gehlbach is a third-year medical student at the University of California, Riverside School of Medicine in Riverside, California, class of 2022. In 2016 he graduated from the University of California, San Diego with a Bachelor of Science in Bioengineering: Biotechnology, in 2018 he graduated from San Diego State University with a Masters of Public Health Epidemiology degree. He is committed to alleviating health disparities and bringing health equity to minorities, refugees, immigrants, migrants, non-native English speakers, the homeless, the poor, and many more. Daniel intends to practice Street Medicine in Southern California and continue to expand efforts to care for the underserved, model by example, and eventually lead and train the next generation of physicians and medical staff.