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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”.
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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 • Exploitation • Maldistribution of wealth and resources • Corporations • Environmental Destruction • War • Lack of international cooperation
Voltaire “The comfort of the rich rests upon an abundance of the poor”
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 Midwives And Country Doctors
Photography Poverty, Hunger, and Homelessness
Photography Environmental Degradation
