Social Justice and Medical Practice

Life History of a Physician of Social Medicine

Merrill Singer, Rebecca Allen

• Publisher: Routledge
• Year: 2017
• eBook ISBN:
  9781351621533
• Topic: Medicine
• Subtopic: Health Care Delivery

How do we understand and respond to the pressing health problems of modern society? Conventional practice focuses on the assessment and clinical treatment of immediate health issues presented by individual patients. In contrast, social medicine advocates an equal focus on the assessment and social treatment of underlying social conditions, such as environmental factors, structural violence, and social injustice.

Social Justice and Medical Practice examines the practice of social medicine through extensive life history interviews with a physician practicing the approach in marginalized communities. It presents a case example of social medicine in action, demonstrating how such a practice can be successfully pursued within the context of the existing structure of twenty-first-century medicine. In examining the experience of a physician on the frontlines of reforming health care, the book critiques the restrictive nature of the dominant clinical model of medicine and argues for a radically expanded focus for modern-day medical practice.

Social Justice and Medical Practice is a timely intervention at a time when even advanced health care systems are facing multiple crises. Lucidly written, it presents a striking alternative and is important reading for students and practitioners of medicine and anthropology, as well as policy makers.

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1

ALTERNATIVES IN MEDICAL PRACTICE AND THEIR SOCIAL AND PERSONAL IMPLICATIONS

Wherever the art of medicine is loved, there is also a love of humanity.

Hippocrates

A Molecular Understanding of Disease

Many technical changes and modification of points of view notwithstanding, the central thrust of biomedicine, from research to training, to clinical practice, remains centered on the molecular understanding of disease, as it has since the mid-nineteenth century. The roots of this way of thinking about human health extend deeper in time to the fifteenth century, with the rise of the practice of anatomical dissection in Europe and the belief that opening up corpses would reveal “the causes of pathology lurking in the body” (Lock and Nguyen 2010: 29). In the eighteenth century, medical practitioners began to see the body as an integrated system that could be clinically examined using agreed-upon procedures to determine the nature and location of disease. This conception was significantly advanced with the rise of “germ theory” in the following century, including the view that specific infectious diseases were caused by specific microorganisms that invaded the body. The end result, as Candia, Banavar, and Losert (2013: 3) affirm, was that “gaining a molecular understanding of disease [became] the holy grail of current biomedical research and related interdisciplinary fields.”

In clinical practice, as patients know well from personal visits to their doctors, this approach is actualized as individually focused physician review and recording of patient symptoms, physical examination, and the use of internal body data collection using various technologies (e.g., radiographic imaging, laboratory tests) to determine if a disease is present, to establish its nature, and to decide on a treatment course. Underlying conventional clinical practice is an understanding—or path for comprehending—what disease is from a biomedical perspective. This understanding is constructed within contemporary biomedicine as the product of a joint project carried out by the fields of molecular biology (which examines the components that make up cells and organisms), biochemistry (which studies the biomolecules of the body and the chemistry behind biological processes), and genetics (especially the analysis of deviance from normal gene patterning). The end result of this approach to health knowledge is a particular way of thinking about disease as a disruption, breakdown, or error at the molecular level that has adverse consequences at higher levels of complexity, especially the cellular and organismic levels.

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The Patient-Centering of Healthcare?

In recent years, however, there has been much internal healthcare establishment and media discussion of a paradigm shift in biomedicine that includes a broadening of understanding about the nature of disease. This shift involves a new emphasis on what has been called patient-centered care that is delivered by a multidisciplinary provider team that incorporates concerns beyond the biological level (Anderson 2014, Beck 2015). Various factors have pushed for change. Most notable was popular dissatisfaction with rising medical costs.

In 2002, the average household was spending about $2,300, or just under 5 percent of its total income, on healthcare. This was an increase from 1999, when the average was under $2,000, or about 4.5 percent of household income. As medical costs continued to increase, employers began shifting more costs to their employees, forcing people in growing numbers to drop health insurance coverage or reduce their purchase of other goods and services. Employer healthcare premiums increased by almost 75 percent in the years 2000–05 and employee contributions for individual and family health insurance plans increased at about the same rate (Kaiser Family Foundation 2016). Smaller companies began to cancel work-based health insurance. As a result, the rate of coverage of employees at smaller companies declined from 68 percent in 2000 to 59 percent in 2005. Overall the proportion of employees who received health coverage from their employer dropped by 4 percentage points and, between 2000 and 2004, the rate of people without insurance for the entire year grew by 1.5 percentage points (Gould 2005). As Elise Gould (2005) notes “many prime-age working adults were left stranded by the drop in coverage and fell into the ranks of the uninsured. Middle-income Americans between the ages of 25 and 54 were 26.7% more likely to be uninsured in 2004 than in 2000.”

The Commonwealth Fund Biennial Health Insurance Survey in 2003 showed that over 75 million Americans (or 37 percent of the adult population) were having difficulty paying their medical bills, and many people were beginning to accumulate medical debt. This led people to not seek needed care and suffer the health consequences. Specifically, the study found that almost two-thirds of people with either a medical bill or debt problem were forced to not get needed care. This was three times bigger than the rate of care avoidance in households that were not enduring health-related financial difficulties. Nearly one of every three adults in the US (approximately 61 million people) reported that they had problems paying medical bills in 2003 (Doty et al. 2005).

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Suffering from medical debt also impacted other issues faced by families. A survey of low- and middle-income households found that half reported having medical debt and a quarter of those reported subsequent housing problems as a result (Seifert 2005). Himmelstein and colleagues (2005) studied individuals who filed for bankruptcy in five federal courts and found that about half reported medical factors pushed them into debt. In a follow-up national study, Himmelstein and colleagues (2009) found that over 60 percent of individual bankruptcies were of medical origin, with most people (92 percent) succumbing to debts of over $5,000. Over the period of these two studies (2001–07), the proportion of bankruptcies attributed to medical bills rose by just below 50 percent. Moreover, a telephone survey by the Access Project revealed that low- and middle-income households had to turn to credit cards to pay for medical care, raising their overall debt and increasing their economic vulnerability (Zeldin and Rukavina 2007). Although uninsured respondents had the highest levels of credit card debt, even those with health insurance were not completely exempt. Kohn and colleagues (2005) examined the scope and consequences of medical costs among people living in Kansas and found that medical bills were exhausting family savings and sending households into crushing debt. The result of these dire developments was a rising cry nationally for reform and relief from the far-reaching consequences of rising medical costs.

By 2007, the US had the highest healthcare costs relative to the size of its economy of any in the world, and yet almost 50 million citizens (approximately 16 percent of the population) lacked health insurance coverage (U.S. Census Bureau 2008). Lack of health insurance coverage can be dire. In 2009, a study by researchers at Harvard University (Wilper et al. 2009) found almost 45,000 excess deaths annually in the US among Americans lacking health insurance. Uninsured adults have been found to be at least 25 percent more likely to die prematurely than adults who have private health insurance. This is in no small part because the uninsured are six times more like to go without medical screenings that might detect significant illness in a timely manner, and they are much less likely to have received preventive care. Consequently, the uninsured are more likely to be diagnosed with a disease in an advanced stage than insured individuals. Ironically, in the end, they are forced to pay more for medical care, by as much as 2.5 times, than the insured (Families USA 2012). In his successful run for the presidency, Barack Obama emphasized the need for healthcare reform to cut costs and extend health insurance coverage. This stance was reflected in the passage of the federal Patient Protection and Affordable Care Act (ACA), or so-called “Obamacare,” which was signed into law in 2010 and is discussed more fully in Chapter 2. In addition to extending coverage, the new law required that essential health benefits include mental health, preventive and wellness services, and chronic disease management, placing legal pressure on the healthcare system for further reform.

Yet, the ACA notwithstanding, current estimates do not paint a rosy picture. National health spending increases in the US for the period between 2015 and 2025 are projected to average 5.8 percent or about 1.3 percentage points faster growth than the gross domestic product. By the end of this period, healthcare will represent 20.1 percent of the total economy based on the use of actuarial and econometric modeling methods used by health economists (Keehan et al. 2016).

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Unfairness

Another factor pressing for change has been the great health inequalities found in American society. As Oberlander (2006: 246) stresses, “Unfairness is arguably a cornerstone of the U.S. health care system.” The 2001 report on healthcare issued by the Institute of Medicine (2000) emphasized that the healthcare delivery system in the US does not provide consistent, high-quality medical care to all people. Rather, and not surprisingly for those familiar with the healthcare system, the report noted that quality of care was found to vary by gender, ethnicity, geographic location, and socioeconomic status. The following year, based on a review of over a hundred studies, the Institute of Medicine (2002) issued a follow-up report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” that concluded that racial and ethnic minorities in the United States are less likely to receive routine medical procedures and more likely to experience a lower quality of health services. Healthcare inequality, the report pointed out, exists across ethnic lines even among people with similar incomes, insurance coverage, and medical conditions. Thus the report indicated African Americans and Hispanics are less likely to be given appropriate heart medication or receive bypass surgery compared to Whites with similar cardiac conditions. Further, they are less likely to receive dialysis or transplants when suffering from kidney disease. Use of cancer diagnostic tests and established treatments were also found to not be equitably used. As a result of such findings, Alan Nelson, the former president of the American Medical Association and chair of the committee that oversaw the writing of the report, stated: “The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them” (Roach 2002: 26).

The Social Gradient

Mounting research findings on the importance of social factors in health has played a role pushing for a rethinking of the dominant biomedical paradigm. A key figure in directing attention to the social determinants of health was Michael Marmot, Professor of Epidemiology and Public Health at the University College of London. During his career, Marmot has conducted trail-breaking work on the role of social and economic inequality in health. As part of this effort, he examined the findings from the famous Whitehall studies of British civil servants. The original Whitehall Study was an investigation of cardiovascular disease prevalence and mortality rates among male civil servants between the ages of 20 and 64. A second study, the Whitehall II Study, examined the health of over 10,000 civil servants aged 35–55. In his analysis, Marmot found that the lower the employment grade and income of a public employee the higher was his or her risk from most causes of death, a phenomenon called the “social gradient” (Marmot et al. 1978, Marmot et al. 1991a, Marmot et al. 1991b). Notably, even middle-class individuals have poorer health than those above them in the socioeconomic hierarchy, while those in the lowest ranks of employment have the worst health. Expanding on this insight, in 1998, Wilkerson and Marmot (1998), and members of the International Centre for Health and Society at University College London, published “The Solid Facts,” a research-based policy statement on how social conditions—like the quality of one’s neighborhood of residence—can impact health. In the Scottish city of Glasgow, for instance, research shows that people who live in poor districts have a life expectancy that is twelve years shorter than those dwelling in affluent districts (NHS Health Scotland 2004). Similarly, in the US, African American men who live in poor neighborhoods tend to live much shorter lives than wealthier White men living in more affluent neighborhoods. In Washington, DC, for example, in 1990, the life expectancy gap between White and Black men was 14.4 years and has not radically changed since then (Friedman and Jennings 2013). Among technologically developed nations, people living in the US have the second highest risk of dying from noncommunicable diseases like diabetes and the fourth highest risk of dying from communicable or infectious diseases (World Health Organization 2011). While death rates from noncommunicable diseases like those of the cardiovascular system have everywhere been in decline, it is less the case in the US. In fact, higher mortality is characteristic of the US across multiple categories of diseases, including respiratory diseases, endocrine disorders, congenital anomalies, and neuropsychiatric conditions. The US also has a dramatically higher rate of death from violence, especially gun-related violence. In 2003, the rate of homicide in the US was just under seven times higher than other wealthy countries, but the rate of gun-related homicide was almost twenty times higher (Richardson and Hemenway 2011). As a result of these cross-country differences in mortality rates, there are large differences in life expectancy at birth among wealthy nations. In 2007, men living in Switzerland and women living in Japan had the longest life expectancies by gender, respectively. The US, by contrast, ranked last among males and next to last among females. This translates into shorter lives for people in the US by approximately 3.7 years for males and 5.2 years for females compared to other rich countries (Ho and Preston 2011). Within-country mortality variances also are of note. For example, African American infants in the US are more than twice as likely as White infants to die before their first birthday (National Center for Health Statistics 2012). Among African American males who have fewer than 12 years of education, life expectancy in 2008 was 14.2 years shorter than for White males with 16 or more years of education (Olshansky et al. 2012).

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Based on widespread interest in their policy statement, Wilkinson and Marmot subsequently were asked by the World Health Organization Regional Office for Europe to produce an updated edition (Wilkinson and Marmot 2003). The level of interest in the new version of “Solid Facts” is indicated by the fact that in the first year after it was posted online it received over 200,000 downloads (Marmot and Wilkinson 2005). In 2005, Marmot chaired the World Health Organization’s Commission on Social Determinants of Health, which issued the impactful report Closing the Gap in a Generation (Commission on Social Determinants of Health 2008). Three years later, he appeared in the widely watched four-hour documentary film series Unnatural Causes: Is Inequality Making Us Sick? (California Newsreel 2008), which examined the social determinants of health based heavily on Marmot’s work on the Whitehall Studies. In 2015, he published the book The Health Gap: The Challenge of an Unequal World (Marmot 2015), which assembled data from around the globe to support a call for a radical change in the conventional biomedical understanding of health by addressing the societal imbalances in power, finances, and resources that create health inequity. The work of Marmot and colleagues is but emblematic of the large body of research and theory affirming the need to address social determinants to improve health; in short, it supports the need for a new consideration of social medicine.

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In light of the growing recognition of nonbiological influences on health, the Medical College Admission Test (MCAT), the gateway to qualifying for medical school admission, began to significantly increase the number of questions it asks about psychological and social factors in health. Further evidence of change in this direction is the fact that, compared to 25 years ago, the humanities now play a larger role in the medical education curriculum, as well as in the questions asked on the MCAT. Moreover, as part of accreditation, medical schools are now required to teach future doctors about core skills in patient-provider communication, the health impacts of prevailing societal inequalities, the role in the health-related behavior of patient culture(s), and the effect of provider bias on effective care delivery.

From the Trenches

Despite these changes, a question remains: how significant and deep-seated are the reforms that have occurred in biomedicine and its perspective in recent years? Has the paradigm really shifted to a new way of thinking about and responding to health issues? Or, as some maintain, have things only been changed enough in small ways to avoid changing at all in big ways? Alternatively, have things actually gotten worse?

In Bruce’s view, based on his experience in the trenches at a clinic that serves poor and ethnic minority patients in the inner city, our healthcare system is now dysfunctional. In part, from his perspective, the problems are embedded in the structure of society, in expressions of structural violence like poverty, lack of food security, and unhealthy living conditions, and in part in the institutional racism that governs access to care. As he sees it, many cities across the country, including Hartford, CT, where the clinic he has worked in is located, are broken. Laying out his vision, he says: “My impulse is to say we have to fix Hartford. People [in positions of authority] get all concerned, and say it’s not politically correct to call it broken. If you say it’s not broken then you’re living under a rock.” The alternative, the way things should be headed, he asserts, is through the development with those living in the neighborhoods of an evidence-based, prioritized, intersectoral plan that addresses not only health problems in the clinic but the structural problems in those neighborhoods and the wider society that give rise to many of the health problems and health disparities he sees in his patients. What is needed is not a scattershot focus on this one problem or that isolated issue, or an approach that is superficial and only produces temporary or minor improvements—a tactic Bruce, referring to the arcade game, calls the “whack-a-mole” plan—but rather a systematic approach to creating “a healthier city in all aspects.” To do this, he maintains, “we need to rebuild the health care system and have adequate resources in places that serve underserved populations so you can assure that people not only have access to health care and medications, but also to adequate housing, healthy food, quality education, jobs . . . that you’re addressing social determinants, that you’re looking at where they live, and that you can assure that people have the tools and resources they need” to stay healthy. What is needed, in short, is social medicine.

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The Alternative of Social Medicine

While recognizing the contributions of conventional biomedicine, social medicine provides an alternative founded on a recognition of the social origins of health and illness. What precisely is this alternative, the one that Bruce, in word and deed, exemplifies? One answer to this question is found in a survey conducted with the active residents, faculty, and alumni of the Residency Program in Social Medicine (RPSM) founded in 1970 by the Montefiore Medical Center in New York City. Montefiore is noteworthy because it created the first hosp...

Table of contents

• Cover Page
• Social Justice and Medical Practice
• Advances in Critical Medical Anthropology
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• 1 Alternatives in Medical Practice and Their Social and Personal Implications
• 2 The Social Construction of Disease Conception and Treatment in Biomedicine
• 3 Being a Person, Becoming a Doctor3 Being a Person, Becoming a Doctor
• 4 Inside the Beast: An Engaged Physician and Modern Medical Institutions
• 5 Struggling for Health Equity from the Inner City to Rural Farms
• 6 Putting People First: Envisioning a Healthy Society
• References
• Index