Training Activist Physicians:Problems, Solutions, and

Resources

Martin Donohoe

Am I Stoned?

A 1999 Utah anti-drug pamphlet warns:“Danger signs that your child may be smoking marijuana include excessive preoccupation with social causes, race relations, and environmental issues”

Impediments to Public Health and Social Justice

• Medical education• Failures of health care system• Actions of academic medical centers• Scientific Ignorance and

Pseudoscience

Impediments to Public Health and Social Justice

ExploitationMaldistribution of wealth and resourcesCorporationsEnvironmental DestructionWarLack of international cooperation

Voltaire

“The comfort of the rich rests upon an abundance of the poor”

Hudson River, 2009

The State of U.S. Health Care

• 51 million uninsured patients• Millions more underinsured–Remain in dead-end jobs–Go without needed prescriptions due

to skyrocketing drug prices• Est. 51,000 deaths/year due to lack of

health insurance

Headline from The Onion

Uninsured Man Hopes His Symptoms Diagnosed This Week On House

Rudolph Virchow

“Doctors are natural attorneys for the poor … If medicine is to really accomplish its great task, it must intervene in political and social life…”

Care for the Poor

“Doctors are natural attorneys for the poor … If medicine is to really accomplish its great task, it must intervene in political and social life…”

- Rudolph Virchow

Problems with Medical Education

• Social, economic and cultural contributors to health of individuals and populations important but under-emphasized in medical (and other health professions) curricula

• Students idealistic/motivated, but grow increasingly cynical and develop negative/defeatist attitudes as training progresses

Schism between medical schools and schools of public health

•Medical schools more focused on biochemical mechanisms of disease and drug therapies • Public health focused on

populations and societal issues

Social Factors Responsible for Illness and Death

• Deaths in 2000 attributable to:–Low education: 245,000–Racial segregation: 176,000–Low social support: 162,000–Individual-level poverty: 133,000

– AJPH 2011;101:1456-1465

Social Factors Responsible for Illness and Death

• Deaths in 2000 attributable to:–Income inequality: 119,000

(population-attributable mortality – 5.1%)–Area-level poverty: 39,000

(population-attributable mortality – 1.7%)

– AJPH 2011;101:1456-1465

Social Factors Responsible for Illness and Death

• Deaths in 2000 attributable to:–AMI – 193,000–CVD – 168,000–Lung CA – 156,000

– AJPH 2011;101:1456-1465

Harvey Cushing

“A physician is obligated to consider more than a diseased organ, more even than the whole man. He must view the man in his world.”

Medical Ethics• Overemphasizes individual conflicts and

fascinating dilemmas involving expensive technologies (e.g., gene therapy, cloning, face transplants)• Underemphasizes psychological, cultural,

socioeconomic, occupational, and environmental contributors to health

Minimal Training re

• Environmental health• AMA guidelines prohibiting physician

participation in capital punishment• War and peace issues (e.g., Geneva

Conventions)

World Health Organization

“The role of the physician … in the preservation and promotion of peace is the most significant factor for the attainment of health for all.”

Other Problems• Patient and physician dissatisfaction

with current fragmented health care system is growing• Cynicism and burnout common• Interest in primary care

low/inadequate

Ethical Distortions to Help Patients

•Doctors offering varying levels of testing and treatment based on patient’s ability to pay•Physicians “gaming the system”

by manipulating reimbursement rules so patients can receive necessary care

Charity Care and Volunteerism• Almost half of US medical schools

sponsor student-run health clinics for the indigent•However, the proportion of

physicians providing charity care has declined over the last decade

Approaches to Teaching Activism

• History• Literature• Photography• Other

Important Historical Figures in Medicine/Public Health and Social Justice

• Florence Nightingale• Rudolph Virchow• Margaret Sanger• Thomas Hodgkin• Albert Schweitzer• Charles Dickens• Upton Sinclair

The Role of Literature

• Promotes empathy, critical/creative thinking, flexibility, non-dogmatism, self-knowledge

• Encourages ethical thinking• Allows for group discussion/debate

Identification with doctor authors (e.g., Keats, Chekhov, Maugham, Williams)

Homelessness

Doris Lessing

“An Old Woman and Her Cat”

From the Doris Lessing Reader (New York: Knopf, 1988)

Poverty

• Orwell, George. How the Poor Die. In Sonia Orwell and Ian Angus, eds. The Collected Essays, Journalism and Letter of George Orwell, IV; In Front of Your Nose, 1945-1950. New York: Harcourt, Brace and World, Inc: pp.223-233.

• Eighner, Lars. Phlebitis: At the Public Hospital. In Travels with Lizbeth. New York: St. Martin’s Press, 1993.

Race and Access to Care

Ernest J Gaines

“The Sky is Gray”

in Gray, Marion Secundy, ed. Trials,Tribulations, and Celebrations: African American Perspectives on Health, Illness, Aging and Loss. Yarmouth, Maine: Intercultural Press, 1992

The Native American Experience

Christopher Columbus, upon meeting the Arawaks of the Bahamas:“They…brought us…many…things…They willingly traded everything they owned…They do not bear arms…They would make fine servants…With fifty men we could subjugate them all and make them do whatever we want.”

The Native American Experience

• Smallpox• Forced migrations• Wars• Loss of land and autonomy• Broken promises• Genocide• Worse health outcomes; high rates of alcohol abuse,

obesity, psychiatric disorders, violence, suicide

The African-American Experience

• Slavery• Drapetomania• Tuskegee Syphilis Study

• Ongoing discrimination, impaired access to health care, worse outcomes

• Persistent suspicion of health care enterprise

Racial Disparities in Health Care:African-Americans

• Equalizing the mortality rates of whites and African-Americans would have averted 686,202 deaths between 1991 and 2000–Whereas medical advances averted

176,633 deaths• AJPH 2004;94:2078-2081

Photography

Nurse MidwivesAnd

Country Doctors

Photography

Poverty, Hunger, and Homelessness

Jacob Riis

Dorothea Lange

Rachel Adams

James Nachtwey

Photography

Environmental Degradation

W Eugene Smith: Minamata Disease

W Eugene Smith: Minamata Disease

W Eugene Smith: Minamata Disease

Sebastiao Salgado: Mining

Sebastiao Salgado: Mining

Sebastiao Salgado: Mining

Sebastiao Salgado: Mining

Photography

War

Robert Capa

W Eugene Smith

James Nachtwey

Solutions

• ↑ public health education• ↑ emphasis on global bioethics and

social justice• ↑use of history, literature,

photography, and art in curriculum

Solutions

• Interdisciplinary education• Community partnerships• Work with the underserved

(locally and globally)

Solutions

• Read activist journals–AJPH, Mother Jones, Dollars and Sense, The

Progressive, Harpers, Z Magazine, The Progressive, In These Times, Bulletin of Atomic Scientists, Hightower Lowdown

• Join activist groups–PSR, PNHP, PHR, UCS, AI, PP, Greenpeace,

etc.

Political Solutions• Vote (physician voter turnout low)• Run for office (physician-legislators

rare)• Lobby legislators–Shift focus from reimbursement

rates to social justice issues

Solutions

• Research-based health activism courses• Social medicine residencies• Websites/Blogs

Websites/Blogs• Social Medicine Portal:

http://www.socialmedicine.org/ • Medicine and Social Justice Blog:

http://medicinesocialjustice.blogspot.com/ • Public Health and Social Justice:

http://www.publichealthandsocialjustice.org or http://www.phsj.org

Additional Resources

• NYU Literature, Arts, and Medicine Database: http://litmed.med.nyu.edu/Main?action=new

• Public Citizen’s Health Research-Based Health Activism courses: http://www.citizen.org/hrg/activistcour/index.cfm

“First they came for the Jews”by Pastor Niemoller

“First they came for the Jews, and I did not speak up, for I was not a Jew.

Then they came for the communists, and I did not speak up for I was not a communist.

Then they came for the trade unionists, and I did not speak up, for I was not a trade unionist.

Then they came for me, and there was no one left to speak up for me.”

Günter Grass

“The first job of a citizen is to keep your mouth open.”

African Proverb

"If you think you are too small to have an impact, try going to bed with a mosquito in your tent"

Contact Information

Public Health and Social Justice Website

http://www.publichealthandsocialjustice.org

http://www.phsj.orgmartindonohoe@phsj.org