Intersectionality and interseccionalidad-the best of both worlds

Abstract

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.

Keywords: Interseccionalidad; Intersectionality; Latin America; North America; Public health; Social determinants of health; Social medicine.

Fig. 1

Cup 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).

Fig. 2

Depiction 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 inequity: 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 lens: 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 lens: 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 worlds: 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.

Fig. 3

Adapted 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 at: https://orwh.od.nih.gov/sites/orwh/files/docs/womens-health-rnd-opportunity-map_2023_508.pdf.