Training Activist Physicians: Problems, Solutions, and Resources

1
Training Activist PhysiciansProblems,
Solutions, and Resources

• Martin Donohoe

2
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

3
Impediments to Public Health and Social Justice

• Medical education
• Failures of health care system
• Actions of academic medical centers
• Scientific Ignorance and Pseudoscience

4
Impediments to Public Health and Social Justice

• Exploitation
• Maldistribution of wealth and resources
• Corporations
• Environmental Destruction
• War
• Lack of international cooperation

5
Voltaire

• The comfort of the rich rests upon an abundance
  of the poor

6
Hudson River, 2009
7
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

8
Headline from The Onion

• Uninsured Man Hopes His Symptoms Diagnosed This
  Week On House

9
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

10
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

11
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

12
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

13
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 20111011456-1465

14
Social Factors Responsible for Illness and Death

• Deaths in 2000 attributable to
• Income inequality 119,000 (population-attributabl
  e mortality 5.1)
• Area-level poverty 39,000 (population-attributabl
  e mortality 1.7)
• AJPH 20111011456-1465

15
Social Factors Responsible for Illness and Death

• Deaths in 2000 attributable to
• AMI 193,000
• CVD 168,000
• Lung CA 156,000
• AJPH 20111011456-1465

16
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.

17
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

18
Minimal Training re

• Environmental health
• AMA guidelines prohibiting physician
  participation in capital punishment
• War and peace issues (e.g., Geneva Conventions)

19
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.

20
Other Problems

• Patient and physician dissatisfaction with
  current fragmented health care system is growing
• Cynicism and burnout common
• Interest in primary care low/inadequate

21
Ethical Distortions to Help Patients

• Doctors offering varying levels of testing and
  treatment based on patients ability to pay
• Physicians gaming the system by manipulating
  reimbursement rules so patients can receive
  necessary care

22
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

23
Approaches to Teaching Activism

• History
• Literature
• Photography
• Other

24
Important Historical Figures in Medicine/Public
Health and Social Justice

• Florence Nightingale
• Rudolph Virchow
• Margaret Sanger
• Thomas Hodgkin
• Albert Schweitzer
• Charles Dickens
• Upton Sinclair

25
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)

26
Homelessness

• Doris Lessing
• An Old Woman and Her Cat
• From the Doris Lessing Reader (New York Knopf,
  1988)

27
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. Martins
  Press, 1993.

28
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

29
The Native American Experience

• Christopher Columbus, upon meeting the Arawaks
  of the Bahamas
• Theybrought usmanythingsThey willingly
  traded everything they ownedThey do not bear
  armsThey would make fine servantsWith fifty men
  we could subjugate them all and make them do
  whatever we want.

30
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

31
The African-American Experience

• Slavery
• Drapetomania
• Tuskegee Syphilis Study
• Ongoing discrimination, impaired access to health
  care, worse outcomes
• Persistent suspicion of health care enterprise

32
Racial Disparities in Health CareAfrican-America
ns

• 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 2004942078-2081

33
Photography

• Nurse Midwives
• And
• Country Doctors

34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
Photography

• Poverty, Hunger, and Homelessness

40
Jacob Riis
41
Dorothea Lange
42
Rachel Adams
43
James Nachtwey
44
Photography

• Environmental Degradation

45
W Eugene Smith Minamata Disease
46
W Eugene Smith Minamata Disease
47
W Eugene Smith Minamata Disease
48
Sebastiao Salgado Mining
49
Sebastiao Salgado Mining
50
Sebastiao Salgado Mining
51
Sebastiao Salgado Mining
52
Photography

• War

53
Robert Capa
54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
W Eugene Smith
61
James Nachtwey
62
Solutions

• ? public health education
• ? emphasis on global bioethics and social justice
• ?use of history, literature, photography, and art
  in curriculum

63
Solutions

• Interdisciplinary education
• Community partnerships
• Work with the underserved (locally and globally)

64
Solutions

• Read activist journals
• AJPH, Mother Jones, Dollars and Sense, The
  Progressive, Harpers, Z Magazine, The
  Progressive, In These Times, Bulletin of Atomic
  Scientists, Hightower Lowdown
• Join activist groups
• PSR, PNHP, PHR, UCS, AI, PP, Greenpeace, etc.

65
Political Solutions

• Vote (physician voter turnout low)
• Run for office (physician-legislators rare)
• Lobby legislators
• Shift focus from reimbursement rates to social
  justice issues

66
Solutions

• Research-based health activism courses
• Social medicine residencies
• Websites/Blogs

67
Websites/Blogs

• Social Medicine Portal http//www.socialmedicine.
  org/
• Medicine and Social Justice Blog
  http//medicinesocialjustice.blogspot.com/
• Public Health and Social Justice
  http//www.publichealthandsocialjustice.org or
  http//www.phsj.org

68
Additional Resources

• NYU Literature, Arts, and Medicine Database
  http//litmed.med.nyu.edu/Main?actionnew
• Public Citizens Health Research-Based Health
  Activism courses http//www.citizen.org/hrg/activ
  istcour/index.cfm

69
First they came for the Jewsby 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.

70
Günter Grass

• The first job of a citizen is to keep your mouth
  open.

71
African Proverb

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

72
(No Transcript)
73
Contact Information

• Public Health and Social Justice Website
• http//www.publichealthandsocialjustice.org
• http//www.phsj.org
• martindonohoe_at_phsj.org