Thursday, June 28, 2012

Retail clinics: power to the patient

If you’re a primary care doctor, as I am, you hear a lot of complaining about retail clinics, often denigrated as “doc in a box”, although most are staffed by Nurse Practitioners or Physician’s Assistants. Most commonly located in pharmacies (well, the hypertrophied pharmacies of national chains such as CVS and Walgreen’s), they have also appeared in other large retail stores such as Wal-Mart where thousands of people go every day expecting to get all that they need in one location. If you can get everything from food to big-screen TVs, car parts to drugs, why not health care?

The reason primary care doctors are concerned is that it more directly competes with what they do than what sub-specialists do. No one is (yet) worried that these clinics will do colonoscopy, not to mention cardiac catheterization or orthopedic surgery. Plus, the main “legitimate” argument against them from primary care physicians is the lack of continuity in this setting, and sub-specialists are not overly concerned with this issue. They do believe in continuity for the problem being treated if it is for a defined time (e.g., pre, during, post surgery) or longer-term for the problem that they care for (heart disease, cancer). But people are not using retail clinics for these things; they may go for blood pressure and glucose and cholesterol checks and refills of prescriptions for these conditions, but they are not expecting such clinics to manage complex disease. Hopefully.

In a recent “Viewpoint” in JAMA, Christine Cassel, an internist, geriatrician and ethicist who is at the American Board of Internal Medicine, writes about this topic in “Retail clinics and drugstore medicine”.[1] It is a generally positive review, noting how well such clinics meet the needs of busy people for fast, convenient and generally effective care. She notes that these clinics, in general, “…have a limited scope of services defined by widely accepted treatment guidelines for acute illnesses,” that “Many have extended hours and are open on weekends, have embraced electronic medical records, and refer patients to a primary care physician if they do not have one,” and that “Research done by third parties has suggested that clinics provide equal-quality care and lower costs than other settings. Reported patient satisfaction is high.” It seems to me that these are all good things; that we should be applauding such access to care. If we rue the transfer of income from ourselves and our institutions to the mega-corporations who run these clinics and hire the staff, it is understandable, but not in itself something we can expect others to be overly concerned with.

Dr. Cassel observes how these clinics help other health professionals, including pharmacists, work at the top of their license and skill set. She notes that while there still are problems with retail clinics, especially their integration with the rest of the health care system, they are making progress. Their corporate owners want them to be integrated, to be sure that they can continue to make money taking cash or insurance for diagnosis and treatment of straightforward problems that can be cared for in such settings, and can refer out for other problems.

The fact is that “integration”, or even communication, within the traditional health care system is much more the exception than the rule. We see patients who have been to the Emergency Department at another hospital who show us the “rest and see your doctor next week” paper that they were handed, with no information (lab, x-ray, even diagnosis) to help that doctor. We see patients who are seen in Mental Health Clinics from which we get no communication about diagnosis or why they are on the medications that they are taking (or even if the patient’s understanding about what medications they are taking is the same as the mental health provider’s). We see patients cared for by other doctors in our own institution who have yet to “go live” on the Electronic Medical Record (EMR) and we have no idea what was done. Indeed, the corporations running retail clinics in their stores appear to be much more willing to invest money in ensuring communication than are most of our medical institutions.

Rather than bemoaning such retail clinics and sitting around in the Doctors’ Lounge complaining about their deficiencies, we should be both welcoming them as partners who can help to meet the acute care needs of people who don’t have (or can’t get in to see) their primary care doctors, and figuring out ways to effectively communicate with them and share information. We should also be figuring out how we can adapt our own practices to incorporate some of their most desirable features. These include:

·       Quick access: what you need when you need it. It is much better to be seen for a minor problem for a relatively small amount of money in such a clinic than in an Emergency Room.
·      Clear pricing: virtually absent in every medical practice other than those sometimes called “cash only” or more negatively “boutique” or “concierge”. Remember that this doesn’t mean that we can only care for those with cash in their pockets; folks can send their bills to insurance companies (although those who are less able, due to illness, age, language, or other issues will need help)
·      Patient centeredness: our practices are almost always doctor-and-staff centered. If we ask ourselves about every aspect of our process and practice “how can this be made simpler, easier and faster for the patient” we will come up with answers. We should never accept “oh, that will be inconvenient for the doctor” as a reason to not change something, but rather figure out how to make it more feasible.

Training practices, with students and residents will have a harder time. The former need more time to learn what they are doing, and should only be observers in such settings. The latter, while they often have the skills (and employ them in “moonlighting” situations) are governed by many rules from their accrediting body that will often “trump” patient-centeredness.

But we need to do this. There are too few primary care doctors to meet everyone’s needs, we need teams, and we need everyone –including the doctors – to be operating at the “top of their license”. We cannot see retail clinics are not the enemy. Rather, we should see them as mirrors, providing us with a reflection of our own deficiencies, and information about how we can not only work together but improve our practices overall.

[1] Cassel CK, “Retail clinics and drugstore medicine”, JAMA, May 23/30, 2012—Vol 307, No. 20, pp. 2151-2.

Thursday, June 21, 2012

Rationing, Waste, and Useless Interventions

Most people, when they or those they love are sick, want things done for them that might be of benefit. Cost is a secondary factor, especially when it is not directly being borne by them because they have health insurance coverage (but if it is going to be costly, that insurance better be good). In general, the order of preference would be for: 1) things that will definitely help; 2) things that might help; 3) things that almost certainly won’t help-but-you-never-know and don’t cause serious harm; and 4) things that won’t help and may very well cause serious harm.

It might seem superficially as if most people wouldn’t want #4 interventions, but surprisingly people opt for them. This is particularly true when the expected outcome is death; if you’re going to die anyway, what harm could be greater? Besides, maybe a miracle will occur. Of course, there can be greater harm than simply dying – death preceded by increased suffering caused by futile attempts at treatment – but when confronting death, many people look at the positives and ignore the negatives. In addition, the decision may be different when made by the person actually facing death (provided s/he is conscious and competent – or has advance directives -- and isn’t doing what the family, not s/he wants, because s/he is used to caring for them) or by his/her loved ones.

This leads into a discussion about rationing of health care resources, which is, appropriately, achieving a lot of attention. Two “Perspective” pieces in the New England Journal of Medicine May 24, 2012, and a “Viewpoint” from JAMA, May 23/30, 2012, address these issues from slightly different, well, perspectives/viewpoints. Howard Brody, MD PhD, in “From an ethics of rationing to an ethics of waste avoidance[1], as a bioethicist, begins with providing the ethics of rationing: “First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.” I’d say “certainly unfair”; while Brody is talking in the abstract, we need only look around at what is actually occurring in the world to know that we have rationing that is unfair. He adds “The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too.”

Brody addresses the current importance of this discussion given recent studies that show that as much of 30% of health care expenditures are “waste”, as opposed to less than 10% that might be attributed to “deliberate fraud.” Eliminating fraud is important, but it is a “one-time” saving, whereas eliminating waste not only represents a bigger number, but, because doing more and more tests is a major driver of rising health costs, may represent a way to “bend the cost curve.” Of course, as I noted, what is “waste” can depend upon ones perspective, values, and even degree of selfishness. Certainly because, as Brody notes, one person’s health expense (even if it is “waste”) is another person’s income, this is not going to be an easy discussion.

Brody cites the case of treatment of advanced metastatic breast cancer with high-dose chemotherapy followed by autologous bone marrow transplantation, which was “…initially thought to offer perhaps a 10% chance of a significant extension of life for patients who would otherwise be fated to die very soon. Insurers’ refusal to pay the high costs of this last-chance treatment did much to torpedo public trust in managed care during the 1990s. Data now suggest that the actual chance of meaningful benefit from this treatment is zero and that the only effect of the treatment was to make patients’ remaining months of life miserable.” However, it could have gone the other way; maybe longer experience would have shown it to be more effective. The “torpedoing of public trust” was surely enhanced by protests from advocacy groups as well as from physicians and hospitals that benefited financially from these procedures. Another result, noted by Volpp et al., in JAMA Assessing value in health care programs”[2], is that “Many insurers, including Medicare, are continuing to cover bevacizumab for metastatic breast cancer, despite the unanimous recommendation by a US Food and Drug Administration panel that it not be covered because it is not helping patients to live longer, does not control their tumors, and exposes them to serious adverse effects, and despite an average annual cost of $99,000.”

Volpp and his colleagues  argue that, in health care, return-on-investment (ROI) cannot always be measured directly as positive in dollar terms, and is less so as the pool (everyone, a big company, a small company, an individual) is reduced:
What would happen if the rule were applied to every health care decision that is made? Besides childhood vaccination and flu shots for the elderly, few health care services save money. The positive return-on-investment criterion is not applied to most health care services because almost nothing satisfies it. Medicare is prohibited by law from considering cost in coverage decisions, and other insurers tend to follow suit, even if the benefits are small and the costs very large. Would anyone ever ask, ‘What is the return on investment in treatment of this patient’s cancer?’ This is not a meaningless question, but almost certainly one that most people would think inappropriate to ask.”
They add “It certainly does not make sense to use one criterion—Are there clinical benefits?—for coverage decisions for treatments and a different criterion—Are health care savings greater than program costs?—for preventive services or for delivery system innovations designed to improve health;” however, we certainly do.

The third article, “Beyond the ‘R Word’? Medicine’s New Frugality”[3] by M. Gregg Bloche MD JD, takes a more policy, political, and law-oriented approach toward understanding what might happen in limiting health care expenditures. He discusses the medical “luxury tax” (on “Cadillac plans”) and notes that while this is not having a big impact now, with the threshold at $23,000 a year, it will in the future because costs of medical care (and insurance) rise faster (at least 2% and often more) than the consumer price index (CPI), while the threshold for the tax is 1% above CPI. He suggests that “Employers
will pay the tax, but workers will bear its burden as firms shrink salaries to cover the cost.”

This is really important, and it is another strong argument for a single-payer health insurance program that will cover everyone. Costs do – and will continue to need to be – controlled, and this will result in continued rationing. But that rationing is only ethical when it is explicit and based on medical need, not the character of one’s insurance or socioeconomic status.

[1 Brody H,”From an ethics of rationing to an ethics of waste avoidance”, NEJM 24May2012;366(21):1949-51
[2] Volpp  KG, G Loewenstein, DA Asch, “Assessing value in health care programs”, JAMA 2012May23/30; 307(20):2153-4.
[3] Bloche MG, “Beyond the ‘R word’: medicine’s new frugality”, NEJM 24May2012;366(21):1951-3.

Saturday, June 16, 2012

Beyond Flexner: Taking the Social Mission of Medical Schools to the next level

In my blog entry for June 20, 2010, A New Way of Ranking Medical Schools: Social Mission, I discussed the article by Mullan, Chen and colleagues that had just been published in in the Annals of Internal Medicine, “The social mission of medical education: ranking the schools”. That seminal article provided concrete data on how medical schools ranked based on 3 criteria related to social mission: percent of underrepresented minority students in their classes, percent of graduates practicing in health professions shortage areas (HPSAs) and percent of their graduates actually practicing in primary care following their residency training. Unsurprisingly, the schools at the top of these rankings were a very group than those at the top than of more traditional rankings, such as US News and World Report, which are based on criteria like reputation, selectivity (what percent of applicants are rejected?) and research funding from the National Institutes of Health (NIH). Indeed, those schools that tend to rank at the top in the latter set of criteria were generally at the bottom of the list in social mission.

It didn’t make those traditional "powers" happy to be ranked at the bottom, and so they did the two things usually done by people and organizations who are found to be lacking by the data: they denied that it was true, that somehow the data was wrong, and they attacked the values of social mission, saying, in essence, that the characteristics being measured by the social mission rankings were not the important ones. The important criteria, of course, were those in which they -- the schools ranked low in social mission and high in traditional rankings – did well. Denying the truth of the study was hard, because the statistics used for measuring the 3 social mission criteria were not inaccurate. Mostly, then, their argument was “Oh, that data is old. We are better now!” But the reason the authors looked at graduates from 1999-2001 was that it allowed them to see several years after completing their primary residency training, not only whether graduates were really practicing in HPSAs, but whether they were really practicing in primary care. Medical schools like to count all students entering internal medicine residencies as “primary care”, when only a small percent do not enter subspecialty fellowships or practice as hospitalists and actually end up in primary care. And, in fact, in that 8 year interval, in the first decade of the 2000s, the numbers got worse.

So these critics mostly focused on the second defense, downgrading the importance of social mission. The measures they suggested (which they do well on) were: 1) getting a lot of money to do research (a little self-fulfilling, since the NIH panels that award research grants are largely staffed by people at the institutions that get research grants; in addition, this research is overwhelming done in the basic biomedical laboratory or early clinical trials, not in the community or the general population); 2) having a great reputation so that faculty who want to get big research grants want to come work there and students with high grades, mostly from the elite upper and upper middle class, want to attend, and 3) having a great reputation, so “peer” evaluators will say “yeah, you’re good!”

One can reasonably argue that the 3 criteria examined by Mullan and colleagues do not completely reflect the social impact of medical schools. Other criteria might include creation of community training experiences, community involvement and engagement in providing venues for training and in determining the type of research carried out by medical school investigators, the degree to which research and programs carried out by the medical school decrease health disparities, and the degree to which the health of communities and populations are increased by the activities of the medical school in practice, research, and education. However, these are not the criteria that the traditional “top” schools want to be evaluated on. The fact is that they are doing what they do, and what they do does not address diversity of the workforce, disparities in health, community involvement, or modern models of interprofessional education.

The next step in the Social Missions of Medical Education movement occurred in Tulsa, OK, May 16-18, 2012 at the “Beyond Flexner” conference. 100 years ago Abraham Flexner was commissioned by the Carnegie Foundation to look at medical education in the US. As a result of his report, more than half of US medical schools closed. Those that remained were largely the ones that had adopted a scientific basis for their medical education and were based in or tightly tied with research universities. For over a half-century, these schools grew with emphasis on the biomedical research enterprise and the training of highly skilled subspecialists, and little interest in any kind of social mission. The social movements of the 1960s and 1970s saw the first large number of new medical schools, and then quiescence until this decade, with a number of additional schools being created. Many of those in both the 1970s and 2000s groups manifested, at least initially, a social mission – that is, they had the goal of actually producing doctors and research that would improve the health of the population.

“Beyond Flexner” was co-sponsored by Mullan’s Medical Education Future Studies group from George Washington University and the new University of Oklahoma-Tulsa School of Community Medicine, led by Dr. Gerry Clancy, President of OU-Tulsa. Under Dr. Clancy, OU-Tulsa has transformed from a site for clinical training of a portion of the students from the OU School of Medicine in Oklahoma City to become the first 4-year school officially called “Community Medicine”. It was also one of the 6 schools that were part of the follow-up study of social mission, and whose leaders presented some of their innovations and successes at the conference. Three, including OU-Tulsa, Florida International University, and the AT Still College of Osteopathic Medicine in Arizona, are in the newest group, and have yet to graduate a class. Their contribution was largely in the creative and innovative methods that they are using to select and enroll and educate students, emphasizing diversity, community-based education, dispersion of educational settings, ambulatory (rather than hospital-based) training, emphasis on primary care and concern for the social determinants of health and health disparities. (A fourth new school, the University of Northern Ontario, in Canada, was also part of this group.)

The 3 other schools were part of the prior wave of new schools created in the 1970s and have had significant social impact, Morehouse University, the Southern Illinois School of Medicine, and the University of New Mexico School of Medicine. These are certainly not the only schools that have made a major commitment to social mission, and perhaps they are not in all respects the perfect exemplars, but they are certainly among the leaders in the field. They are part of an international movement of medical schools that were founded in the same period, to create physicians who would have the skills to care for people (primary care), have the knowledge to do research on community and population health, have the relationships to train and work with people in community settings, and have the intelligence to challenge traditional methods of classroom teaching by increasing clinical and interprofessional training experiences. Representatives from these and other schools described pipeline programs, interprofessional training, dispersion of training sites, innovative curricula, emphasis on primary care, and many other models and efforts.

The bottom line is that outcomes matter, and that judging a school by the impact that it has on the health of the population is the gold standard. Biomedical research contributes important knowledge that may, someday, impact human health, but this can be done in research institutes (see, for example, Karolinska, Rockefeller, Insitute Pasteur, Stowers) and certainly should not determine the core mission of schools focused on training doctors and other health professionals. The steering committee of “Beyond Flexner” is developing key principles that need metrics to assess outcomes; I would suggest the following:
·       Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?
·       Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?
·       Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?
·       Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?

Maybe by the time of the next “Beyond Flexner” conference, every one of our medical education institutions will have bought into these principles and their implementation, and be able to be examples of how it can and should be done.

Sunday, June 10, 2012

Improving health in poor countries -- and reducing it in the rich

I have recently published the text of my “Withers Lecture” on Social Justice and Health, given at the University of Texas at Houston. In its May 16, 2012 issue, . JAMA published two important “Viewpoint” articles: “Policy making with equity at its heart”,[1] by Michael Marmot, FRCP, and “Primary Health Care in Low-Income Countries: Building on Recent Achievements”,[2] by Jeffrey Sachs, PhD. It is gratifying that these two major figures are writing about the same issues that I am; after all, I cite Dr. Marmot (Sir Michael) in my talk, both for his seminal work on the impact of social class on health (the “Whitehall studies”) and his more recent work as President of the British Medical Association in taking the lead on involving the medical community in addressing the social determinants of health. Dr. Sachs, of the Earth Institute at Columbia, is one of the most important thinkers and actors in the field of international health.

But, in another sense, I am sobered by this, because it is often true that an outpouring of articles citing the evidence for the importance of social action, whether from leaders such as Drs. Marmot and Sachs in JAMA or by bloggers such as myself, are stimulated by attacks and cut-backs in these areas which have already resulted in pain and suffering. Dr. Sachs’ piece is, in this sense, more positive; he reviews successes that have been achieved in poor countries by the use of primary health care strategies. Much of this success has been in “Group I diseases [which] include communicable, maternal, perinatal, and nutritional diseases”, and which he points out are very susceptible to improvement with quite low levels of investment. The successes he points to include reducing the infant mortality rate in many countries (“In the least developed countries, approximately 112 of every 1000 children die before their fifth birthday, as opposed to 8 per 1000 in the developed countries. With a concerted science-based effort, the under-5 mortality rate of the least developed countries could be reduced to less than 30 per 1000 by 2020. Such low under-5 mortality rates have already been achieved, for example, by the Dominican Republic (28 per 1000), Mexico (17 per 1000), and Thailand (13 per 1000).”) He also addresses the issue of malaria, one of the world’s great killers: “Malaria deaths in Africa have declined an estimated 30% from their peak around 2004 with the partial deployment of this new and evolving system.” His article is positive and optimistic, particularly when examining the relatively low cost of interventions that will have such great impact: “Small investments in improved health of the poor have a remarkable return in reduced morbidity and mortality.”

Whether those small investments will continue to be made, however, is an open question. The flamboyant, aggressive, and unabashed attacks on people demonstrated in many laws passed on both the Federal and state level in the US, and the dramatic cuts in social services that have occurred here and in Europe as a result of “austerity” policies”, challenge our ability to maintain health even in developed countries. This is a focus of Dr. Marmot’s article. In a pointed and engaging opening, he writes “In India, there is a cabinet minister for social justice. Would that it were catching, and spread to all government ministers. What a thought: social justice at the heart of all government policy. It would be a radical change from the current set of arrangements, in which many governments are unashamed apostles of self-interest—of their countries, of their partisan supporters or, indeed, of self-interest as a political creed. Given the link between social and economic policy and the health of populations, all ministers should see themselves as ministers of health.”

What a thought, indeed! Dr. Marmot, like Dr. Sachs, cites a list of health problems that could be largely addressed by social intervention and a concern for equity. Unlike those on Dr. Sachs’ list, however, these are interventions are being curtailed rather than expanded. He cites the report “Closing the Gap in a Generation” from the World Health Organization’s (WHO) Commission on the Social Determinants of Health (CSDH) and emphasizes that “…although traditionally efforts to prevent ill health have focused on causes—such as inadequacies in sanitation, nutrition, and shelter in deprived populations, and on unhealthy environments and behaviors among those not deprived—focus should shift to the causes of the causes.” And the cause of the causes is social and socioeconomic inequity – not inequality, because it does not require that everyone be equal – but inequity, which he defines as “systematic inequalities in health between social groups that are deemed to be avoidable by reasonable means.” He challenges the international focus on solely achieving growth of GDP, which has generated the austerity measures that have already caused so much suffering, and instead suggests considering the “…report of the Commission on the Measurement of Economic Performance and Social Progress (established by the French government and led by Joseph E. Stiglitz, Amartya Sen, and Jean-Paul Fitoussi) that argues for broader measures of social and economic progress than simply GDP.” And, as argued by another Nobel Prize winner, economist Paul Krugman, austerity policies don’t even do much for growing GDP!

So, while progress in health has been made with small investments in developing countries, developed countries are seeing both their health and social structure degraded as “solutions” to a financial crisis brought on by the greed of multi-billionaire bankers and investors. These “solutions” are implemented in a way that ensures that the prosperity of those perpetrators is guaranteed while the price is paid by the middle and lower income groups. These “solutions” have neatly dovetailed with radical right-wing (often incorrectly labeled “conservative”) social agendas. This is true not only of cutbacks in direct support for social programs, but in union rights, and most profoundly in the rights of women to protection from violence, opportunity for education, and control of their reproduction. The systematic and hypocritical character of these attacks in the US is well-documented in a New York Times editorial from May 20, 2012, “The Campaign Against Women”.  

While Sachs may be correct in noting that the in developing countries improvement is low cost, his concern that this is not happening sufficiently “While the developed economies grapple with health systems that cost several thousand dollars per person per year and often spend hundreds of thousands of dollars on a treatment to eke out an additional few months of life,” may also miss the point. In developed countries, we spend on this high-tech, high-profit, low-yield medical interventions but we still do not spend on the social interventions that would truly make a difference in health.

Perhaps progress in the developing world can be a model for the rest of us. 

[1] Marmot MG, “Policy making with equity at its heart”, JAMA. 2012;307(19):2033-2034. doi:10.1001/jama.2012.3534
[2] Sachs J, “Primary Health Care in Low-Income Countries: Building on Recent Achievements”, JAMA. 2012;307(19):2031-2032. doi:10.1001/jama.2012.4438

Monday, June 4, 2012

Justice, Social Justice, Health and Health Care, Part IV

This is the final installment of four that comprise the Henry A. Withers lecture. The entire talk will be posted as a GoogleDoc, with a link on the left frame.

How can physicians and physician organizations be involved in reducing health disparities and increasing social justice?

Physicians can perform work that is medical, but outside their usual work in the hospital or office. They may volunteer in free clinics (including student-run clinics), in school-based health centers, and at health fairs. They can participate in the development of sustainable communities in rural areas through creating and working in Health Extension Services, modeled on the Cooperative Extension services for agriculture that exist in our land-grant universities, and in urban areas. They can do international volunteer work as well.

Dr. Michael Marmot, who led the “Whitehall studies” that demonstrated there is a linear relationship between health and social class, was President of the British Medical Association last year. He led an effort by the BMA to identify the real causes of health disparities and ways of ameliorating them. “Social determinants of health: what doctors can do”, published by BMA in October 2011, is an effort to identify the principles to be used in addressing social determinants of health, the evidence for effectiveness of specific interventions, including direct and indirect impacts, and also identify the best practices being implemented. Their policy objectives are very reasonable, but unusual for a medical association:

1.    Give every child the best start in life
2.       Enable all children, young people and adults to maximize their capabilities and have control over their lives
3.       Create fair employment and good work for all
4.       Ensure healthy standard of living for all
5.       Create and develop healthy and sustainable places and communities
6.       Strengthen the role and impact of ill health prevention

One example that the report develops in greater depth is for “cold housing”. They cite the existing data on the direct impact of cold housing on health:
  • Countries which have more energy efficient housing have lower excess winter deaths (EWDs).
  • EWDs are almost three times higher in the coldest quarter of housing that in the warmest quarter.
  • Around 40% of EWDs are attributable to cardiovascular diseases.
  • Around 33% of EWDs are attributable to respiratory diseases.
  • Mental health is negatively affected by fuel poverty and cold housing for any age group.
  • Cold housing increases the level of minor illnesses such as colds and flu and exacerbates existing conditions such as arthritis and rheumatism.
  • Cold housing negatively affects dexterity and increases the risk of accidents and injuries in the home
as well as the indirect impacts: 
  • Cold housing negatively affects children’s educational attainment, emotional well-being and resilience.
  • Fuel poverty negatively affects dietary opportunities and choices.
  • Investing in the energy efficiency of housing can help stimulate the labour market and economy, as well as creating opportunities for skilling up the construction workforce.
This provides a thorough, evidence based, and very sobering portrayal of the health consequences of what is not normally considered a “medical” problem by a major medical association. Beyond identifying the problem, the BMA identified places and programs which were effectively addressing them. They created – and are continuing to add to – a searchable database, so one community can benefit from the work done elsewhere.

Educating medical students and residents: the Core Competencies

How can we train physicians in the US to be aware of and work on issues of health disparities, social determinants of health, and social justice? The Accreditation Council for Graduate Medical Education (ACGME) has 6 ‘overall competencies’ for all medical residents, which have also been adopted for medical students by the Liaison Committee for Medical Education (LCME). Two of these, Professionalism and Systems-Based Practice, touch on issues of social justice by emphasizing ethical principles, the physician-patient relationship, confidentiality, and working with and communicating within teams. Hixon, Yamada, Farmer and Maskarinec (unpublished work) suggest adding a specific Social Justice competency which would focus on teaching about and developing experiences to work on the equitable distribution of health resources, social determinants of health, recognizing systemic injustice, advocating for positive change in the health care system and society, eliminating structural violence, and developing a specific understanding about how social issues lead to poor health.

In each setting in which medicine is practiced, the conditions leading up to the current illness  –  and the circumstances to which patients will be returning when they leave the hospital or the clinic – need to be considered. To the extent that they are adverse for their health, physicians need to be taught how they might be involved in altering them. One example might be in international electives; Hixon et al. suggest replacing the question of “How can this help me improve my clinical skills?” with “How might I best serve the destitute sick?” or “How might I best improve their situation?” Note that even the question “How can this help me improve my clinical skills?” is a step up from “How can I have a good time as a ‘medical tourist’?

Social Justice: Philanthropy or Government

Only the government has the size and power to make a sufficient difference in the social determinants of health and health disparities. Some years ago, when the new Health Care Foundation of Greater Kansas City announced their first grants, $20 million to agencies caring for the underserved and uninsured, their Executive Director noted that the previous day the state of Missouri had cut $626 million from their Medicaid program, and there was no way even such a well-endowed foundation could make up that difference. Farmer’s work in Haiti with Partners in Health has been more successful that some other NGOs because they specifically partner with the government there.

  • Social conditions are the biggest determinant of health status
  • Social inequities (lack of social justice) results in health disparities
  • Addressing inequities decreases disparities and the burden of ill health
  • Physicians can and should be involved in efforts to address disparities and advocate for social justice
Two more quotations:
Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustice which make philanthropy necessary.” Martin Luther King, Jr
Or, perhaps more “pithy”: “Charity isn’t a good substitute for justice” Jonathan Kozol.

And, finally, from Dr. King:
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

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