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”

Outline

 Impediments to public health and social justice  What you can do  Individually  Group  Heroes of Medicine and Public Health

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

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

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

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

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

The State of U.S. Health Care

 49 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

The State of U.S. Health Care

 US ranks near the bottom among westernized nations in life expectancy and infant mortality  22% of US children live in poverty  Gap between rich and poor widening  Racial inequalities in processes and outcomes of care persist

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

Meanwhile, Outside the US…

 1 billion people lack access to clean drinking water  3 billion lack adequate sanitation services  Hunger-related causes kill as many people in 8 days as the atomic bomb killed at Hiroshima

James Nachtwey

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

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

Income Inequality

 Lower life expectancy  Higher rates of infant and child mortality  Short height  Poor self-reported health  AIDS

Income Inequality

 Depression  Mental Illness  Obesity  Crime  Diminished trust in people and institutions

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

Hudson River, 2009

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.”

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.”

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.”

Sebastiao Salgado

Exploitation leads to:

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

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

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

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

Competitive Strategies of Financially Strapped Academic Medical Centers  Increase cash services (botox treatments, cosmetic surgery) and reimbursable, 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

The Medical Brain Drain

 U.S. – 280 physicians/100K people (vs. sub Saharan Africa – 18/100K people)  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

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

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

Corporations

 Purpose: Make money for shareholders  Internalize profits  Externalize health and environmental costs

The Stock Market

 The top 1% of Americans owns 51% of all stocks, bonds, and mutual fund assets  Consequences of Differential Stock Ownership  Corporations are answerable to their shareholders  Governments are answerable (at least in theory) to their citizens (either through elections or revolutions)

Corporations

 Confidential legal settlements keep important public health and safety information secret  May delay governmental intervention, cause unnecessary morbidity and mortality  Corporate crime costs nation 35-150 times as much money as “street crime”

Corporate PR Tactics  Advertising  Greenwashing  Sponsored educational materials  Co-opting scientists and academic institutions

Corporate PR Tactics

 Media control  Lobbying  Astroturfing - artificially-created grassroots coalitions  Corporate front groups

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

Corporations and Health

 The insurance industry  The alliance between GE Medical Systems and NY-Presbyterian Hospital  The American Council on Science and Health

Corporations and Health

 Global Tobacco Treaty  Corporate Agribusiness  Prison-Industrial Complex

Pharmaceutical Industry

 Influence over physicians through control of CME, gifts, research funding  2011 NIH rules require reporting of over $5000 financial largesse from industry (database not public)  Conduct seeding trials to alter prescribing patterns  Secrecy, statistical torturing of data sets, selective publication  Unethical trials in developing world  Poor compliance with Clinical Trials Registry rules

Drug Company Malfeasance

 The pharmaceutical industry is the biggest defrauder of the federal government, as determined by payments made for violations of the federal False Claims Act (FCA)  Accounted for 25% of all FCA payouts between 2000 and 2010  Defense industry – 11%  Has paid out almost $20 billion in civil and criminal penalties over the last 20 years

Breast Milk Substitute Manufacturers  Marketed to women in developing world  Nestlé, others  Discourage (and make more difficult) breast feeding  WHO International Code of Conduct  U.S. has not signed  91% of U.S. hospitals distribute formula packs (which would violate WHO code)

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

Mahatma Gandhi

“ You must be the change you want to see in the world”

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

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

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.”

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

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

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

Jacob Riis

Dorothea Lange

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

Promote peace

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

U.S. Discretionary Spending (2012)

Practice Humility / Know Your Limits

The only solid piece of scientific truth about which I feel totally confident is that we are profoundly ignorant about nature. Indeed, I regard this as the major discovery of the past hundred years.

Lewis Thomas

Contemplate Life and Death, Comfort the Grieving

 Honor dead  Grieve  Awareness of own mortality  Follow-up

Self Care/Education

 Medical students and physicians have above average rates of burnout, mental illness, and suicide  Self Care:  Relationships, sleep, recreation  Support colleagues  Seek help early when necessary  No stigma  Continue your lifelong education

Rudolph Virchow

“You can soon become so engrossed in study, then professional cares, in getting and spending…that you find too late with hearts given away that there is no place in your habit-stricken souls for those gentler influences that make life worth living”

Continue Your Lifelong Education

 Find teachers, mentors, role models  Keep up with the medical literature  Certify/recertify  Question dogma  Encourage collaborative training between professional schools  Advocate for curricular changes

Get Politically Active

 Physicians have an obligation, borne of their privileged status, the public’s investment in their training, and their roles as stewards of the public’s health, to be politically active and ensure that our leaders provide for the sickest among us.

Political Solutions

 Vote (physician voter turnout low)  Run for office (physician-legislators rare)  Lobby legislators (visits > calls > letters > emails)  Shift focus from reimbursement rates to social justice issues

Speak Up for the Disenfranchised

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

Have Faith in Your Ability to Affect Change

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

Solutions

 Restructure tax system  Decrease taxes on work and savings  Increase taxes on wealthy  Maximum income (France, England considering)

Solutions

 Restructure tax system  Increase capital gains tax from 15% to (at least) prior 25% rate  Resume transaction tax on stock sales/purchases  Increase taxes on destructive activities (e.g., carbon emissions, toxic waste generation)

Power to the People, Not the Corporations

 Support living wage laws  Combat corporate crime  “Just say no” to pharmaceutical company gifts and trinkets

Campaign for Fair and Representative Elections  Publicly financed campaigns and campaign finance reform  Members of Congress spend between 30% and 70% of their time fundraising  50% of Senators and 42% of Representatives become lobbyists after leaving office

Campaign for Fair and Representative Elections  Proportional representation  Instant runoff voting/cumulative voting/range (rating) voting  Halt disenfranchisement, overturn voter restriction laws

Campaign for Fair and Representative Elections  Open debates, free air time for candidates  Proportional representation  Instant runoff voting/cumulative voting/range (rating) voting

Solutions Based on the Precautionary Principle “When evidence points toward the potential of an activity to cause significant, widespread or irreparable harm to public health or the environment, options for avoiding that harm should be examined and pursued, even though the harm is not yet fully understood or proven”

The Precautionary Principle: Practical Essentials  Give human and environmental health the benefit of doubt  Include appropriate public participation in the discussion  Gather unbiased, scientific, technological and socioeconomic information  Consider less risky alternatives

The Precautionary Principle in Action

 Montreal Protocol to phase out ozone damaging chlorofluorocarbons  REACH (Registration, Evaluation and Authorization of Chemicals)

Save the Planet Together

 Combat environmental degradation and global warming  E.g., reduce/reuse/recycle  Support local economies and fair trade policies  Encourage international cooperation

U.S. International Non Cooperation/Isolationism  Failure to sign or approve:  Kyoto Protocol on Climate Change  International Covenant on Economic, Social, and Cultural Rights  Convention on the Prohibition of Anti-Personnel Land Mines

U.S. International Non Cooperation/Isolationism  Failure to sign or approve:  Comprehensive Nuclear Test Ban Treaty  Convention on the Rights of the Child  Convention on the Elimination of Discrimination Against Women  Convention for the Suppression of Traffic in Persons

U.S. International Non Cooperation/Isolationism  Failure to sign or approve  The Stockholm Convention on Persistent Organic Pollutants  The Basel Convention on the Control of Transboundary Movements of Hazardous Wastes  WHO International Code of Marketing of Breast Milk Substitutes

U.S. International Non Cooperation/Isolationism  Failure to sign or approve  WHO International Code of Marketing of Breast Milk Substitutes  UN Convention on the Rights of Disabled Persons

U.S. International Non Cooperation/Isolationism  Failure to follow World Court Decisions  Failure to recognize International Criminal Court

Promote Fairness and Prevention

 Fight for more equitable distribution of medical research funds and health care dollars  Reverse brain drain

Prevention

 2-4% of national health care expenditures  40% of US mortality due to tobacco, poor diet, physical inactivity, and misuse of alcohol  Every $1 invested in community-based programs to increase physical activity, improve nutrition, and prevent tobacco use saves $5.60 in health care costs

Prevention

 Every $1 spent on building biking trails and walking paths would save nearly $3 in medical expenses  Every $1 spent on wellness programs, companies would save over $3 in medical costs and almost $3 in absenteeism costs

Public Health Spending

 Public health spending minimal  Mortality rates fall 1-7% for every 10% increase in public health spending

Premature Deaths in the U.S.

 10% due to inadequate medical care  60% due to behaviors, social circumstances, and environmental exposures

Address 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

Address 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

Address 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

Maldistribution of Wealth is Deadly  880,000 deaths/yr in U.S. would be averted if the country had an income gap like Western European nations, with their stronger social safety nets

Benefits of Education

 For every $1 spent on early childhood education, up to $17 are saved from increased school achievement, improved health, reduced crime, and reduced reliance on public assistance  Income increases 11% for every year of education

Benefits of Education

 College graduates live 5 years longer than high school dropouts  Eliminating educational inequities would have saved 8X as many lives as medical advances from 1996-2002

Grow Community Partnerships

 Community-Oriented Primary Care  Evaluation  Needs Assessment  Implementation  Planning  Repeat  Community-Based Participatory Research

Obtain a Global Health Education, Work with the Underserved  Increased interest in primary care  Increased service/volunteering in underserved communities  Higher performance on USMLE step II  Better H and P skills  Greater awareness of socioeconomic issues and public health  Language skills

Advocate for Women’s Rights

 Increase access to comprehensive reproductive health services  Recognize domestic violence  Combat female genital cutting

Education and Action

 Educate yourself, your students and your patients  Become active in an organization  Use the media  Enjoy Yourself

The health impact pyramid Frieden, T. R. Am J Public Health 2010;100:590-595

Copyright ©2010 American Public Health Association

Contemporary Activist Organizations  Physicians for Social Responsibility, Physicians for Human Rights, Amnesty International  Union of Concerned Scientists, Public Citizen’s Health Research Group  PNHP, Doctors without Borders, Doctors for Global Health  Greenpeace, Sierra Club, HCWH, NRDC, ED, No Dirty Gold, PANNA  Planned Parenthood, NARAL  Others

Work Together

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.“ - Margaret Mead

Heroes: 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

Heroes: 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

Heroes: 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

Heroes: Rudolph Virchow

 Passed hygiene standards for public schools  Set new standards of training for nurses  Improved local hospital system

Heroes: 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…”

Heroes

 Dr. Thomas Hodgkin (abolitionist and opponent of British oppression of native populations in South Africa and New Zealand)  Nurse Margaret Sanger (founder of the family planning movement in the US)  Dr. Albert Schweitzer (won Nobel Peace Prize in part for developing a missionary hospital for the poor in Gabon, Africa)

Heroes

 Florence Nightingale (feminist, founder of the modern nursing profession, and advocate for hygienic hospitals)  Dr. Salvador Allende (assassinated president of Chile and promoter of better living conditions for the poor and working classes).

 *The quiet and unknown*

Heroes

YOU!

Public Health and Social Justice Website http://www.publichealthandsocialjustice.org

http://www.phsj.org

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