The aim of this thesis is to argue what it means to embody clinical competence for treating im/migrant patients. Im/migrants are a distinct yet heterogeneous patient population. They come to the U.S. for a variety of reasons, with a great diversity of backgrounds, upbringings, experiences, and ways of life. Considering the structural violence and push and pull factors directly connected to reasons for im/migration and experiences of distress upon settlement in the U.S., the central framework of this thesis is im/migration as a structural determinant of health. The operations of social structures, through policy, law enforcement, and discriminatory belief systems, make im/migrants structurally vulnerable. When healthcare providers treat im/migrant patients from a structurally informed approach to care, the context of these patients’ needs become more apparent and likelihood of positive health outcomes increases. Central to this structural approach, as I explain, is understanding how to best communicate with, gain the trust of, and provide effective social interventions for im/migrant patients relative to the operations of violent social structures. Im/migrant status truly is a determinant of health in its own right, and accordingly, care for im/migrant patients is also a specialized clinical realm with specific skills and competencies. As I argue, healthcare providers can only attain—embody—the competence for treating im/migrants through an awareness of how social structures affect these patients’ lives and modifies the delivery of care.

Background South Africa has experienced the most severe consequences of the HIV/AIDS pandemic. Every community has been affected in some way, many experiencing huge increases in mortality,particularly before antiretroviral therapies (ART) were readily available. However, the micro-level understanding of the HIV epidemic in South Africa is weak, because of a lack of detailed data for most of the population. This thesis is based on detailed individual follow-up in the Agincourt Health and Demographic Surveillance Site (HDSS) located in the Agincourt subdistrict of Mpumalanga Province and investigates micro-level determinants of HIV epidemiology and the impact of treatment provided. Methods The Agincourt HDSS has followed a geographically defined population since 1992,approximately the time when the HIV/AIDS epidemic first became apparent. This population based surveillance has included capturing details of all deaths, with cause of death determined by verbal autopsy, as well as the geographical location of individual households within the overall Agincourt area. Background information on the roll-out of ART over time was also recorded. Results A comparison immediately before and after the major roll-out of ART showed a substantial decrease in HIV-related mortality, greater in some local communities within the area than others. Individual determinants associated with a decreased risk of HIV/AIDS mortality included proximity to ART services, as well as being female, younger, and in higher socioeconomic and educational strata. There was a decrease in the use of traditional healthcare sources and an increase in the use of biomedical healthcare amongst those dying of HIV/AIDS between periods before and after the roll-out of ART. Conclusions Understanding micro-level determinants of HIV/AIDS infection and mortality was very important in terms of characterising the overall epidemic in this community. This approach will enable public health interventions to be more effectively targeted towards those who need them most in the continuing evolution of the HIV/AIDS epidemic.