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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