Activism in Medicine: Historical Perspectives and Modern Challenges

1. Activism in Medicine: History, Literature, and Contemporary Issues and Movements Martin Donohoe

2. Overview • Background • Issues • History • Literature • Quotes and Photos • Education, the media, and democracy • What you can do

3. Portland, OregonMount Hood

4. Multnomah Falls, Oregon

5. 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”

6. 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.”

7. Medicine and Public Health • Schism between the fields • Witnessed victims vs. “statistical” victims • Precautionary Principle

8. Important Contributions of Public Health • Water and food safety • Sanitation • Vaccination • Fluoridation • Iodine supplementation of table salt • Seat belts, air bags • Bed nets for malaria prevention • Barriers to decrease bridge suicides

9. Reasons for Underfunding of Public Health (NEJM 362;18:1657-8) • Benefits of public health programs lie in the future • Beneficiaries of public health measures are generally unknown • Benefactors are often unknown • Opposition to public health programs often political, corporate • Medical care usually promoted by corporate interests

10. Important Historical Figures in Medicine/Public Health and Social Justice • Florence Nightingale • Clara Barton • Margaret Sanger • Thomas Hodgkin • Albert Schweitzer • Rachel Carson • Lois Gibbs

11. Important Historical Figures in Medicine/Public Health and Social Justice • Charles Dickens • Anton Chekhov • Upton Sinclair • George Orwell • William Carlos Williams

12. Rudolph Virchow • Founder of modern pathology • Thrombosis, pulmonary embolism, leukocytosis, leukemia • Member of state and local government for over 30 years • Founded journal Medical Reform

13. Rudolph Virchow • Argued that many diseases result from “the unequal distribution of civilization’s advantages” • Advocated public provision of medical care for the indigent • Promoted universal education

14. Rudolph Virchow • Worked to outlaw child labor • Improved water distribution and sewage system • Enhanced food inspection process • Published study of skull volumes to dispute myth of larger Aryan brains

15. Rudolph Virchow • Passed hygiene standards for public schools • Set new standards of training for nurses • Improved local hospital system

16. 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…”

17. Issues • Access to care • Boutique medicine • Racial, sexual and SES discrepancies in outcomes • Homelessness • Effects of poverty on health • Hunger

18. U.S. Health Care • Per capita expenditure on health care: • U.S. = $9,255 • Typical poor African/Asian country = $5-50 • Even so, U.S. had 42 million uninsured (28 million now, post-PPACA), ranks 24th worldwide in overall population health as judged by disability-adjusted life expectancy

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

20. Racial Disparities in Health Care:African-Americans • Higher maternal and infant mortality • Higher death rates for most diseases • Shorter life expectancies • Less health insurance • Undergo fewer diagnostic tests / therapeutic procedures

21. 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

22. 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 • Income inequality: 119,000 (population-attributable mortality – 5.1%) • Area-level poverty: 39,000 (population-attributable mortality – 1.7%) • AJPH 2011;101:1456-1465

23. Deaths per year • Tobacco = 400,000 (+ 50,000 ETS) • Obesity = 300,000 • Alcohol = 100,000 • Microbial agents = 90,000 • Toxic agents = 60,000 (likely higher) • Firearms = 35,000 • Sexual behaviors = 30,000 • Motor vehicles = 25,000 • Illicit drug use = 20,000

24. Diseases 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

25. Issues • Excessive pharmaceutical company influence, dubious marketing practices • Women’s rights issues: • Violence against women • Access to reproductive health care • Female genital cutting • Political, legal, and educational marginalization

26. Status of Women • Economic discrimination • Women do 67% of the world’s work • Receive 10% of global income • Own 1% of all property • A woman in a developing country walks an average of 6 km/day to obtain water

27. Issues • Environmental degradation • Overpopulation • Air and water pollution • Toxins • Deforestation • Global warming

28. Issues • Environmental degradation • Unsustainable agricultural and fishing practices • Famine • Commodification of world’s food and water supply by corporations • Species loss

29. Poverty and Inequality in the U.S. • US: 15% of residents and 22% of children live in poverty • Food insecurity common • Gap between rich and poor widening, largest of any industrialized nation

30. Poverty Worldwide • 650 million people lack access to safe, clean drinking water • 2 billion have no electricity • 2.3 billion do not have adequate sanitation services • Hunger kills 18,000 people per day, most under age 5 • 1.8 million child deaths/year

31. Consequences of Pollution • Death (1/6 of world’s yearly deaths linked to contaminated air, water, soil, and workplaces) • NAS: Pesticides in food could cause up to 1 million cancers in the current generation of Americans

32. Air Pollution

33. Air Pollution

34. Toxic Exposures • 13,000-15,000 deaths per day worldwide from water-related diseases • In developing countries, 90-95% of sewage and 70% of industrial wastes are dumped untreated into the local water supply • 1 in 4 U.S. citizens lives within 4 miles of a Superfund site • Lead and mercury exposure multi-billion dollar problems

35. Water Pollution:Bathtub=Toilet=Source of Drinking Water

36. Toxins:Minimata Disease - W Eugene Smith

37. Deforestation

38. Greenland’s Ice Cap Melting: 1992

39. Greenland’s Ice Cap Melting: 2002

40. Greenland’s Ice Cap Melting: 2005

41. Climate Change: Drought

42. Famine

43. Factory Farms • # 1 polluters of American waterways • Agriculture accounts for 70% of U.S. antibiotic use • #1 contributor to food-borne, antibiotic-resistant infections (CDC) • Source of MRSA, other resistant bacteria

44. Factory Farming

45. Overfishing:Factory Trawlers

46. Dynamite Reef Fishing

47. Species Loss = Lost Pharmacopoeia • Drugs from plants and native peoples’ health knowledge • More than 1/2 of the top 150 prescription drugs contain an active compound derived from or patterned after natural products-e.g. digoxin, vincristine, paralytic agents, etc. • Of the more than 250,000 known flowering species, <0.5% have been surveyed for medicinal value

48. A Cure for Cancer?

49. Social Justice Issues • Maldistribution of wealth • Overconsumption (“affluenza”) • Rise of the corporation • 53 of the world’s 100 largest economies are private corporations; 47 are countries • Minimum wage ≠ Living wage • Third World debt crisis • Human rights abuses

50. Maldistribution of Wealth • U.S: Richest 1% of the population owns 50% of the country’s wealth; poorest 90% own 30% • Widest gap of any industrialized nation • 3 richest men in the US have more wealth than 50% of the population