Activism 101 for Medical Students and Physicians

1. Do Something: Activism 101 for Medical Students and Physicians Martin Donohoe

2. 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”

3. Outline • Impediments to public health and social justice • What you can do • Individually • Group • Heroes of Medicine and Public Health

4. Impediments to Public Health and Social Justice • Medical education • Failures of health care system • Actions of academic medical centers • Scientific Ignorance and Pseudoscience

5. Impediments to Public Health and Social Justice • Exploitation • Maldistribution of wealth and resources • Corporations • Environmental Destruction • War • Lack of international cooperation

6. Schism between medical schools and schools of public health • Dates back to the early twentieth century • Medical schools more focused on biochemical mechanisms of disease and drug therapies • Public health focused on populations and societal issues

7. Public Health • Institute of Medicine: ¼ to ½ of medical students should earn the equivalent of a masters in public health • Only 10% of students at US public health schools are physicians, down from 60% in the 1960s

8. Medical Ethics Today • Overemphasizes individual conflicts and fascinating dilemmas involving expensive technologies (e.g., gene therapy, cloning, face transplants) • Underemphasizes the psychological, cultural, socioeconomic, occupational, and environmental contributors to health

9. The State of U.S. Health Care • 45 million uninsured patients • Millions more underinsured • Remain in dead-end jobs • Go without needed prescriptions due to skyrocketing drug prices • 45,000 deaths/year due to lack of health insurance

10. Headline from The Onion Uninsured Man Hopes His Symptoms Diagnosed This Week On House

11. The State of U.S. Health Care • US ranks near the bottom among westernized nations in life expectancy and infant mortality • 20-25% of US children live in poverty • Gap between rich and poor widening • Racial inequalities in processes and outcomes of care persist

12. Meanwhile, Outside the US… • One billion people lack access to clean drinking water • 3 billion lack adequate sanitation services • Hunger kills as many individuals in two days as died during the atomic bombing of Hiroshima

13. James Nachtwey

14. The Decline of Medicine? • Patient and physician dissatisfaction with current fragmented health care system is growing • Cynicism and burnout common • Interest in primary care low/inadequate

15. 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

16. 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

17. Income Inequality • Lower life expectancy • Higher rates of infant and child mortality • Short height • Poor self-reported health • AIDS • Depression • Mental Illness • Obesity

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

19. Hudson River, 2009

20. Primo Levi “A country is considered the more civilized the more the wisdom and efficiency of its laws hinder a weak man from becoming too weak or a powerful one too powerful.”

21. Colonial Exploitation • Christopher Columbus’ log entry 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.”

22. Colonial Exploitation • Cecil Rhodes (Rhodesia, Rhodes Scholarship, DeBeers Mining Company): “We must find new lands from which we can easily obtain raw materials and at the same time exploit the cheap slave labour that is available from the natives of the colonies. The colonies would also provide a dumping ground for the surplus goods produced in our factories.”

23. Sebastiao Salgado

24. Exploitation leads to: • Maldistribution of wealth and resources • Environmental degradation • Wars: • Over 250 wars in 20th Century • Most deaths among civilians • Militarism and war divert financial and intellectual resources away from social needs • Weapons of mass destruction

26. Contemporary Research Imbalances and Exploitation • Unethical research on special populations (cultural minorities, prisoners, developing world, etc.) • Majority of phase 3 US drug company trial sites outside US, many in developing countries • 90% of research dollars spent on diseases affecting 10% of the world’s population • Limited access of developing world to results due to scarcity of open-access publications

27. Competitive Strategies of Financially-Strapped Academic Medical Centers • Tuition hikes (→rising medical student debt) • Close public and charity hospitals • Single specialty hospitals

28. Competitive Strategies of Financially-Strapped Academic Medical Centers • Recruit wealthy, non-U.S. citizens as patients • More aggressive billing practices / charging the uninsured higher prices

29. Competitive Strategies of Financially-Strapped Academic Medical Centers • Increase cash services (botox treatments, cosmetic surgery) and reimburseable, covered services (e.g., cardiac catheterization, bone density testing) • Pay sports teams for privilege of being team doctors (in return for free publicity) • Develop luxury primary care clinics

30. The Medical Brain Drain • Five times as many migrating doctors flow from developing to developed nations than in the opposite direction • Example of “inverse care law”: • Those countries that need the most health care resources are getting the least

31. Corporations Dominate the Global Economy • 53 of the world’s 100 largest economies are private corporations; 47 are countries • GM is larger than Denmark and Turkey • Wal-Mart is larger than Israel and Greece

32. Corporations • 90% of transnational corporations headquartered in Northern Hemisphere • 500 companies control 70% of world trade • Corporations shouldered over 30% of the nation’s tax burden in 1950 vs. 8% today

33. Corporations • Purpose: Make money for shareholders • Internalize profits • Externalize health and environmental costs • Corporate crime costs nation 35-150 times as much money as “street crime”

34. Corporate PR Tactics • Advertising • Greenwashing • Sponsored educational materials • Co-opting scientists and academic institutions

35. Corporate PR Tactics • Media control • Lobbying • Astroturfing - artificially-created grassroots coalitions • Corporate front groups

36. Corporate PR tactics • Invoke poor people as beneficiaries • Characterize opposition as “technophobic,” anti-science,” and “against progress” • Portray their products as environmentally beneficial despite evidence to the contrary

37. Corporations and Health • The insurance industry • The alliance between GE Medical Systems and NY-Presbyterian Hospital • The American Council on Science and Health

38. Corporations and Health • Global Tobacco Treaty • Corporate Agribusiness • Prison-Industrial Complex

39. Pharmaceutical Industry • Influence over physicians through control of CME, gifts, research funding • Conduct seeding trials to alter prescribing patterns • Secrecy, statistical torturing of data sets, selective publication

40. Corporatization and Inequalities Threaten Democracy • True democracy demands an informed citizenry (education), freedom of the press (media), and involvement (will, time, money) • Democracy is critical to public health

41. Mahatma Gandhi You must be the change you want to see in the world

42. Learning and Practicing Medicine is a Privilege No matter where I might find myself, every sort of individual which it is possible to imagine in some phase of his development, from the highest to the lowest, at some time exhibited himself to me. - William Carlos Williams

43. Listen to Your Patients • Eye contact • Don’t interrupt • Patient’s life and illness as story • Pay attention to social, cultural, and economic contributors to illness • Doctor as patient

44. Anatole Broyard • To most physicians, my illness is a routine incident in their rounds, while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity.

45. Listen to Your Patients “Most people have a furious itch to talk about themselves and are restrained only by the disinclinations of others to listen. Have an open mind and an interest in human beings. Human nature may be displayed before you and if you have not the eyes to see you will learn nothing.” Somerset Maugham

46. Know Your Patients “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.” - Harvey Cushing

47. 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

48. Jacob Riis

49. Dorothea Lange

50. Care for All Equally “A society should be judged not by how it treats its outstanding citizens but by how it treats its criminals” -Fyodor Dostoyevsky