Do Something: Activism 101 for Medical Students and Physicians Martin Donohoe.
-
Upload
bertha-sullivan -
Category
Documents
-
view
219 -
download
1
Transcript of 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
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
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
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.”
Exploitation leads to:
• Maldistribution of wealth and resources• Environmental degradation• Wars:– Over 250 wars in 20th 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
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
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
SolutionsBased 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*
Public Health and Social Justice Website
http://www.publichealthandsocialjustice.org
http://[email protected]