Transcript Activism in Medicine: History, Literature, and Contemporary Issues and Movements Martin Donohoe Overview  Background  Issues  History  Literature  Quotes and Photos  Education, the media,

Activism in Medicine: History,
Literature, and Contemporary
Issues and Movements
Martin Donohoe
Overview
 Background
 Issues
 History
 Literature
 Quotes and Photos
 Education, the media, and democracy
 What you can do
Portland, Oregon
Mount Hood
Multnomah Falls, Oregon
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”
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.”
Medicine and Public Health
Schism between the fields
Witnessed victims vs. “statistical”
victims
Precautionary Principle
Important Contributions of Public Health
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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
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
Important Historical Figures in Medicine/Public
Health and Social Justice
 Florence Nightingale
 Clara Barton
 Margaret Sanger
 Thomas Hodgkin
 Albert Schweitzer
 Rachel Carson
 Lois Gibbs
Important Historical Figures in Medicine/Public
Health and Social Justice
 Charles Dickens
 Anton Chekhov
 Upton Sinclair
 George Orwell
 William Carlos Williams
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
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
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
Rudolph Virchow
 Passed hygiene standards for public
schools
 Set new standards of training for
nurses
 Improved local hospital system
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…”
Issues
 Access to care
 Boutique medicine
 Racial, sexual and SES discrepancies in
outcomes
 Homelessness
 Effects of poverty on health
 Hunger
U.S. Health Care
 Per capita expenditure on health care:
 U.S. = $8,160
 Typical poor African/Asian country = $5-
50
 Even so, U.S. has 49 million uninsured,
ranks 24th worldwide in overall population
health as judged by disability-adjusted life
expectancy
Headline from The Onion
Uninsured Man Hopes His
Symptoms Diagnosed This Week
On House
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
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
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
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
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
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
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
Issues
 Environmental degradation
 Overpopulation
 Air and water pollution
 Toxins
 Deforestation
 Global warming
Issues
 Environmental degradation
 Unsustainable agricultural and
fishing practices
 Famine
 Commodification of world’s food and
water supply by corporations
 Species loss
Poverty Worldwide
 1.1 billion people lack access to safe, clean
drinking water
 1.8 million child deaths/year
 2 billion have no electricity
 2.6 billion do not have adequate sanitation
services
 Hunger kills 18,000 people per day, most
under age 5
Consequences of Pollution
 Air pollution causes approximately
60,000 - 75,000 premature deaths/yr. in
U.S., 7 million worldwide
 NAS: Pesticides in food could cause up
to 1 million cancers in the current
generation of Americans
Air Pollution
Air Pollution
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
Water Pollution:
Bathtub=Toilet=Source of Drinking Water
Toxins:
Minimata Disease - W Eugene Smith
Deforestation
Greenland’s Ice Cap Melting: 1992
Greenland’s Ice Cap Melting: 2002
Greenland’s Ice Cap Melting: 2005
Climate Change: Drought
Famine
Factory Farms
 # 1 polluters of American waterways
 Agriculture accounts for 70% of U.S.
antibiotic use
 #1 contributor to food-borne, antibioticresistant infections (CDC)
 Source of MRSA, other resistant bacteria
Factory Farming
Overfishing:
Factory Trawlers
Dynamite Reef Fishing
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
A Cure for Cancer?
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
Maldistribution of Wealth
U.S: Richest 1% of the population
owns 40% of the country’s wealth;
poorest 90% own 30%
Widest gap of any industrialized
nation
Maldistribution of Wealth
 Less than 4% of the combined wealth
of the 225 richest individuals in the
world would pay for ongoing access to
basic education, health care, adequate
food, safe water, and adequate
sanitation for all humans (UNDP)
Overconsumption (“Affluenza”)
 U.S. = 6.3% of world’s population
 Owns 50% of the world’s wealth
 U.S. responsible for:
 25% of world’s energy consumption
 33% of paper use
 72% of hazardous waste production
George Orwell
“Some people are more equal
than others”
Hudson River, 2009
Voltaire
“The comfort of the rich rests
upon an abundance of the poor”
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.”
Issues
 War and Militarism:
 Diversion of economic resources and
intellectual capital
 Prejudice/hate crimes
 Erosion of civil liberties
 Weapons of mass destruction
 Military = world’s largest polluter
The Military: Diversion of Resources
Away from Health Care
 3 hours world arms spending = annual WHO
budget
 1/2 day of world arms spending = full childhood
immunizations for all world’s children
 3 weeks of world arms spending/yr. = primary
health care for all in poor countries, incl. safe
water and full immunizations
 “War on Terror” creating enormous U.S. debt
War and Peace
 World military budget = $1.8 trillion in 2012
 230 times what the UN spends on
peacekeeping
 US:
 Largest military budget, largest arms
supplier
 Greatest debtor to UN peacekeeping fund
“Every gun that is made, every warship
launched, every rocket fired, signifies
in the final sense a theft from those
who hunger and are not fed, those who
are cold and not clothed.”
~ Dwight D. Eisenhower
“The problem in defense spending is to
figure out how far you should go
without destroying from within what
you are trying to defend from without.”
~Dwight D. Eisenhower
World Military Spending (2012)
U.S. Discretionary Spending
(2012)
Kuwaiti Oil Fires – Gulf War I
The Value of the History of Medicine
 Provides context for contemporary
practices
 Promotes pride in our field and sense
of mission to carry on work of our
predecessors
 Fosters humility regarding utility of
novel technologies
Brigham and Women’s Hospital
 Established 1966 through merger of
Peter Bent Brigham Hospital, Robert
Breck Brigham Hospital, and Boston
Hospital for Women
 1847: First administration of anesthesia
in childbirth
Brigham and Women’s Hospital:
History
 1913: Harvey Cushing named surgeon-in-
chief
 Father of modern neurosurgery
 Used X-rays to diagnose brain tumors,
electrical stimuli to study sensory cortex
 Helped develop Bovie electrocautery
 Discovered Cushing’s Disease
Brigham and Women’s Hospital:
History
 1923: Elliott Cutler performs world’s first
successful heart valve surgery
 1926: William Murphy, George Whipple, and
George Minot discover that liver extracts
cure pernicious anemia
 Awarded Nobel Prize
 1939: Soma Weiss named physician-in-chief
– co-discoverer of Mallory-Weiss tears
Brigham and Women’s Hospital:
History
 1949: first use of cortisone for rheumatoid
arthritis
 1949: Carl Walter develops world’s first
blood bank
 1954: Joseph Murray performs first
successful human organ (kidney) transplant
 Awarded Nobel Prize
Brigham and Women’s Hospital:
History
 1962: D/C cardioversion used for first time
to restore normal heart rhythm in A-fib
 Home of first CCU
 Today: one of the largest non-university
recipients of research funding from NIH
 Contemporary leaders in medicine
The Role of Literature
 Vicarious experience
 Explore diverse philosophies
 Promotes empathy, critical thinking,
flexibility, non-dogmatism, self-knowledge
 Encourages creative thinking
 Allows for group discussion/debate
Why Use Literature
 Encourage appreciation of non-medical
literature
 Develop reading, analytical, speaking and
writing skills
 Promote ethical thinking (narrative ethics)
 Identification with doctor authors (e.g.,
Keats, Chekhov, Maugham, Williams)
 Can be used in a variety of settings
Homelessness
Doris Lessing
“An Old Woman and Her Cat”
From the Doris Lessing Reader (New York:
Knopf, 1988)
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
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.
 Checkhov, Anton. Letter to AF Koni, January 26, 1891,
Letter to AS Survivor, March 9, 1890. In Norman
Cousins, ed. The Physician in Literature
Philadelphia: WB Saunders, 1982.
Impediments to Public Health and
Social Justice
 Political climate
 Scientific Ignorance
 Pseudoscience
 Damaged educational system
 The corporate media
 All lead to the decline of democracy
Bush Administration
 Key administrators/committee
members/regulators former industry
representatives and/or lobbyists
 Privatization of public services
 Corporate profit before public good
 Unsound/distorted/suppressed science
Bush Administration
 Rollbacks of key environmental laws
 Lax enforcement of existing laws
 Huge tax cuts primarily benefit wealthy
 Federal and state government deficits
astronomical
 Program and funding cuts
 Increased trade deficit
 Obama – ?change?
Obama Administration
 Large industry influence
 Very slow progress
Would You Sign a Petition to
Ban Dihydrogen Monoxide?
1. It can cause excessive sweating and vomiting
2. It is a major component in acid rain
3. It can cause severe burns in its gaseous state
4. It can kill you if accidentally inhaled
5. It contributes to erosion
6. It decreases effectiveness of automobile brakes
7. It has been found in tumors of terminal cancer
patients
Environmental and Geographic
Ignorance
 A majority of Americans believe that electricity in
the U.S. is produced in nonpolluting ways
 25% knew that majority (70%) comes from oil, coal and
wood
 Percent of US teens unable to locate the following
on a map:
 United States – 11%
 Pacific Ocean – 29%
 Japan – 58%
Pseudoscientific Beliefs
Percentage of Americans who believe “at least to
some degree” in these “phenomena”
 Astrology
 UFOs
 Reincarnation
 Fortune-Telling
1997
37%
30%
25%
14%
1976
17%
24%
9%
4%
Ignorance/Pseudoscientific Beliefs
 Half of US citizens do not believe in
evolution and do believe that humans
and dinosaurs coexisted (2007)
 40% think scientists still generally
disagree about evolution
 Only 12% of U.S. Protestant pastors
believe in evolution
 70% believe in global warming
Pseudoscientific Beliefs
 37% believe places can be haunted (2007)
 25% believe in UFOs (2007)
 24% believe in astrology (2009)
 16% believe that people with the “evil eye”
can cast curses or harmful spells
Pseudoscientific Beliefs
 22% of Americans don’t know whether an atomic
bomb has ever been dropped (2000)
 20% of Americans don’t know the earth revolves
around the sun (1999)
 18% believe in Bigfoot and the Loch Ness Monster
(2007)
 8% of men / 18% of women believe in astrology and
fortune tellers (2007)
 14% have consulted a psychic or fortune teller (2009)
Obfuscating Influence of Religion
 Onion Headline:
Greenwash
 Public relations / ad campaigns
 Chevron’s “People Do” Campaign,
butterflies/refinery
 Grants to a few scientists who
challenge environmental warnings
 Tobacco ads in 1950’s
Astroturf
 Artificially-created grassroots coalitions
 Corporate front groups:
 The American Council on Science and
Health
 National Wilderness Institute
 The Foundation for Clean Air Progress
Corporate-sponsored environmental
education materials (examples)
 Exxon’s “Energy Cube”
-“Gasoline is simply solar power hidden in decayed
matter”
-“Offshore drilling creates reefs for fish”
 Pacific Lumber Company
-“The Great American Forest is. . . renewable
forever”
Sponsored Environmental
Education Materials (Examples)
 International Paper
-“Clearcutting promotes growth of trees
that require full sunlight and allows
efficient site preparation for the next
crop”
 American Nuclear Society’s “Activities
with the Atoms Family”
 Dow’s “Chemipalooza”
Textbook Publishers Facilitate
Corporate Messaging
 Scholastic, Inc.
 World’s largest publisher of children’s educational
materials

Found in 90% of U.S. classrooms
 Has taken money from Big Coal, Disney, Microsoft,
Nestlé, and Shell to produce books and lesson plans
 2011: Announces plan to terminate some industry
contracts, set up quasi-independent review board to
review corporate materials
Advertising
“Doubt is our product”
Brown and Williamson Tobacco Company Memo, 1960s
Advertising
 US now spends $290 billion/yr on
advertising
 Almost $1,000/person/yr in the U.S.
 10% of a two-year olds nouns are brand
names
 The average American can recognize over
1,000 corporate logos, but fewer than 10
plants and animals native to his/her locality
Television
 The average American youth spends
900 hrs/yr in school, 1,500 hrs/yr
watching TV
 By age 65, the average American will
have spent 9 yrs watching TV
 Contributor to obesity epidemic
Public Education in Disarray
U.S. Schools ranked lowest among
western nations
↓ funding, infrastructure decaying
1/4 of U.S. Schools have no library
Public Education in Disarray
 Inadequate funding, decaying
infrastructure
 National HS graduation rate 65-70%
 No change from 1970s
 Lower incomes youths 6X as likely to
drop out
 ¼ of Americans functionally illiterate
Public Education in Disarray
 College tuition costs rising
 Increasingly marginalizes poor, minorities
 70% of students come from wealthiest ¼
of US families
 14% from the poorest half
 But 39% of highest-achieving students
from poorest half
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
Ignorance vs. Democracy
“Information is the currency of
democracy”
Thomas Jefferson
The Media
 Most media organizations owned by
multinational, multi-billion dollar
corporations that are involved in a
number of businesses apart from the
media, such as forestry, pulp and paper
mills, defense, real estate, oil wells,
agriculture, steel production, railways,
and water and power utilities
Global Warming: Controversial?
 Of 928 articles in peer-reviewed scientific journals, 0%
were in doubt as to the existence or cause of global
warming
 Of 636 articles in the popular press (NY Times,
Washington Post, LA Times, WSJ), 53% expressed
doubt as to the existence (and primary cause) of global
warming
Science 2004;306:1686-7
(Study covers 1993-2003)
Global Warming
 Global warming:
 400,000 deaths and 5.0 - 5.5 million
disability-adjusted life years lost per
year (Climate Vulnerability Monitor,
WHO, UN Environment Program)
 Expected to double by 2030
 Weather extremes
Lobbying
 Almost 15,000 full-time lobbyists
 Estimates of return on lobbying range from $28 to
$100 for every $1 spent
 Revolving door between lobbyists and Congress
 Between 2001 and 2011, 5,400 former
Congressional staffers left to become lobbyists,
and 605 lobbyists left their positions to work for
Congress
Lobbying
 Pharmaceutical lobby spent $1.3 billion on
lobbying between 1998 and 2007 (more than any
other industry)
 $110 million in first half of 2010
 1,228 lobbyists (2.3 for every member of Congress)
 The pharmaceutical industry is the biggest
defrauder of the federal government
 It has paid out almost $20 billion in civil and
criminal penalties over the last 20 years
Lobbying
 Lobbying groups spent 3.5 billion in
2010 (record)
 All single issue ideological groups
combined (e.g., pro-choice, antiabortion, feminist and consumer
organizations, senior citizens, etc.)
spent well-under $100 million
The “Benefits” of Sterility-Causing
Chemicals in the Workplace?
12 September 1977
Dr. Eula Bingham, Assistant Secretary for Occupational Safety and Health
[Regarding] worker exposure to DBCP.
While involuntary sterility caused by a manufactured chemical may be
bad, it is not necessarily so. After all, there are many people who are now
paying to have themselves sterilized to assure they will no longer be able to
become parents...
If possible sterility is the main problem, couldn’t workers who were old
enough that they no longer wanted to have children accept such positions
voluntarily? Or…some [workers] might volunteer for such workposts as an
alternative to planned surgery for a vasectomy or tubal ligation, or as a means
of getting around religious bans on birth control when they want no more
children?
Sincerely,
Robert K. Phillips, National Peach Council
The Decline of Democracy
 True democracy demands an informed
citizenry (education), freedom of the
press (media), and involvement (will,
time, money)
What you can do
 Explore the history of medicine
 Respect
 Question dogma: “The least questioned assumptions are
often the most questionable” – Paul Broca
 Read great literature
 Patients illnesses are stories
 Take patient’s perspective
 Develop a public health-oriented perspective in
care of patients
 Find your passion
What you can do
 Become active in an organization
 Educate yourself
 Educate your students and your patients
 Use the media
 Volunteer, do pro bono work
 Satisfies your debt to society
 Feeds your soul
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
African Proverb
If you think you are too small
to have an impact, try going
to bed with a mosquito in
your tent
“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.”
Contact Information
Public Health and Social Justice
Website
http://www.phsj.org
[email protected]