Do Something: Activism 101 for Medical Students and Physicians

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

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

• • 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

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 20-25% of US children live in poverty Gap between rich and poor widening Racial inequalities in processes and outcomes of care persist

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

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 Depression Mental Illness Obesity

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 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

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

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 • 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 Conduct seeding trials to alter prescribing patterns Secrecy, statistical torturing of data sets, selective publication

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

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

Attention to Self Care

• • • Attention to relationships, sleep, recreation Support your colleagues Seek help early when necessary – No stigma

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“ - Anita Roddick

Power to the People, Not the Corporations

• • • • Support living wage laws Restructure tax system 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 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

Promote Fairness and Prevention

• • Fight for more equitable distribution of medical research funds and health care dollars Focus on prevention – 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

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

Contemporary Activist Organizations • • • • • • • • Amnesty International, Oxfam Partners in Health, Doctors for Global Health PNHP HCWH, NRDC, ED, Greenpeace, Sierra Club, No Dirty Gold, PANNA Union of Concerned Scientists, Public Citizen’s Health Research Group NARAL, Planned Parenthood Physicians for Social Responsibility, Physicians for Human Rights 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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