Social Medicine and the Coming Transformation

Howard Waitzkin, Alina Pérez, Matt Anderson

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781134869077
• Edition: 1
• Topic: Medicina
• Subtopic: Medicina clínica

Social medicine, starting two centuries ago, has shown that social conditions affect health and illness more than biology does, and social change affects the outcomes of health and illness more than health services do. Understanding and exposing sickness-generating structures in society helps us change them.

This first book providing a critical introduction to social medicine sheds light on an increasingly important field. The authors draw on examples worldwide to show how principles based on solidarity and mutual aid have enabled people to participate collaboratively to construct health-promoting social conditions. The book offers vital information and analysis to enhance our understanding regarding the promotion of health through social and individual means; the micro-politics of medical encounters; the social determination of illness; the influences of racism, class, gender, and ethnicity on health; health and empire; and health praxis, reform, and sociomedical activism. Illustrations are included throughout the book to convey these key themes and important issues, as well as on Routledge's webpage for the book, under the Support Materials tab.

The authors offer compelling ways to understand and to change the social dimensions of health and health care. Students, teachers, practitioners, activists, policy makers, and people concerned about health and health care will value this book, which goes beyond the usual approaches of texts in public health, medical sociology, health economics, and health policy.

Chapter 1
What Is Social Medicine?

An Outbreak of Fatal Respiratory Disease – Part One

Imagine that you are a health worker, maybe a nurse or a doctor, working in a rural area in the Southwest United States. Consider how you would respond to the following challenge.

You recently started a job with a community health center in Gallup, New Mexico, a town that adjoins the Navajo Nation.¹ During the past two days, you have cared for three Navajo patients, ranging in age from 21 to 60. They all presented with severe cough, high fever, and weakness. The oldest patient developed adult respiratory distress syndrome and required transfer to the medical intensive care unit (ICU) at the University of New Mexico (UNM) Hospital in Albuquerque. The two younger patients presented with less severe respiratory symptoms, and you are treating them with oral antibiotics. However, when they come in again to see you today, their cough has worsened and they are developing symptoms of respiratory distress.

You call UNM Hospital to arrange for them to be admitted. As part of the admission process, you consult with an epidemiologist who is also an infectious disease specialist. She asks you whether the three patients share any characteristics. You reply that all three live in a remote rural area on the Navajo Nation. She replies that no less than six similar patients have entered ICUs at UNM and other local hospitals during the past week, and three of them have died from respiratory failure. Hantavirus is the apparent infection, she says, and has been confirmed by blood tests. She asks that you notify her if you find out any additional, pertinent information.

QUESTIONS TO CONSIDER AND DISCUSS

In considering these patients, here are some questions to keep in mind:

• How could you determine if an epidemic was developing?
• If you are, in fact, dealing with an epidemic, what can you do to help control it?
• Whom could you turn to for help?
• How does this epidemic reflect larger social factors (sometimes referred to as social determinants)?
• What relationship does this epidemic have to human rights concerns?

You never have seen a case of hantavirus, although you vaguely remember hearing about it once or twice in medical school. You look it up on the U.S. Centers for Disease Control website.² You learn that infected rodents, such as field mice, carry hantavirus. Originally discovered during an epidemic in the Hantan River area in rural Korea, the virus infects humans when they inhale the feces or urine of infected mice or rats. The virus can remain alive in dust and enters the respiratory tract through the nose when people sweep their houses, garages, or barns. There is no known treatment for hantavirus pulmonary syndrome. Among the reported cases in the United States, about 30–40 percent of patients died. While hantavirus infection occasionally affects wealthy people, for instance, those who own ranches, it is overwhelmingly a disease of poverty.

This epidemic of hantavirus actually occurred in 1993 and was the first recognized outbreak of hantavirus in the United States. Sadly, 25 years later people in the Southwest continue to die of the hanta pulmonary syndrome, still mostly in communities affected by poverty and marginalization.

An Outbreak of Fatal Respiratory Disease – Part Two

Now try to imagine yourself as a doctor on December 30, 2019, in Wuhan, a large city in China. Some of your patients have been getting severely ill with a life-threatening pneumonia, requiring hospitalization. You were too young to work in medicine during the epidemic of severe acute respiratory syndrome (SARS) that spread from China to other countries between 2002 and 2004, but you have learned about it in medical school. You know that a coronavirus, called SARS CoV, caused SARS through “zoonotic” spread from bats to civets, the mammals that served as intermediary hosts, and then to humans. SARS had spread throughout east and southeast Asia and also to other countries such as Canada, causing thousands of deaths. You get worried that SARS or a similar infectious epidemic is starting again, so you share this information with medical colleagues who participate in a chat room and ask for feedback. Within days, police authorities accompanied by government public health officials detain you and force you to sign a statement confessing that you were spreading illegal rumors. Eventually COVID-19, caused by a new coronavirus, SARS-CoV-2, spreads rapidly through the population of Wuhan and surrounding areas, and later to nearly the entire world. On February 7, 2020, you die from the same disease at age 33. Later, the Chinese Communist Party exonerates you, apologizes to your family, and names you as a “martyr” of the COVID-19 pandemic.³

Dr. Li Wenliang was one among thousands of heroic health workers worldwide who have sacrificed their comfort, health, and lives during the COVID-19 pandemic on behalf of the individual patients and the populations they serve. So far, nurses in particular, but also nursing assistants, workers at nursing homes and other long-term care facilities, non-professional workers at hospitals, and other “essential” but lowly paid workers have suffered severe illness and death due to their exposure to SARS CoV-2. Often these workers’ illnesses and deaths have resulted from inadequate personal protective equipment (PPE) and other dangerous work conditions inadequately addressed by employers and governments.⁴

Clinical medicine sometimes can become risky for practitioners, but when practitioners try to address the social dimensions of medical problems, their work and lives can become even riskier. The risks can include dangerous treatment by those who hold economic and political power in societies, because the social medicine perspective (as noted in the Preface) can reveal information that those in power rightfully experience as threatening. In later chapters, especially Chapters 8 and 10, we consider those risks in more depth.

On the other hand, epidemics like COVID-19 show why social medicine, despite its risks, is so important, because epidemics always contain crucial social components. Although some people have referred to the COVID-19 pandemic as an “equalizer,” the inequalities in illness and death from COVID-19 actually have followed the same pattern as in other epidemics, and as in many other physical and mental health problems. The worst outcomes have happened in populations that are poor, from minority or indigenous ethnic backgrounds, and suffering from inadequate housing, nutrition, sanitation, discrimination, racism, and other social conditions of marginalization.

Although we previously had decided to begin this book with the hantavirus epidemic that severely impacted the Navajo Nation, COVID-19 has also devastated the same population. Geographically, the Navajo Nation spans the Four Corners area of four U.S. states: New Mexico, Arizona, Utah, and Colorado. As of late April 2020, the rate of COVID-19 per population within the Navajo Nation rose quickly to a level only slightly less than in the so-called “epicenters” of the pandemic in New York and New Jersey. By late May 2020, the infection rate in the Navajo Nation surpassed that of New York state, with 2,680 cases per 100,000 population compared to 1,890 in New York. The Navajo Nation’s rate of infection was about ten times higher than the state of Arizona’s.

In addition to the Navajo Nation, other indigenous populations have shown much higher risks for infection and mortality. For instance, while Navajo and other Native American communities accounted for about 11 percent of New Mexico’s population, they made up 44 percent of the state’s cases of confirmed coronavirus. Living conditions in these communities, especially lack of universal access to clean water and soap, made simple precautions like frequent handwashing difficult to implement. Availability of healthy food also remained problematic for these communities, leading to long-standing elevations of key risk factors for COVID-19 mortality such as diabetes, hypertension, and heart disease.

Such conditions emerged from a legacy of colonialism, where colonizers brought with them infectious diseases such as smallpox, cholera, measles, and typhoid, sometimes introduced intentionally into native communities as essentially genocidal practices. The resulting epidemics wiped out a large majority of the indigenous populations of the Americas. These patterns have affected indigenous communities not only in the Americas but also in other countries and continents, including Africa and Asia, where crowded housing, inadequate nutrition, and lack of clean water have fueled the COVID-19 pandemic.⁵

Inequalities in infection rates, illnesses, and mortality during the pandemic also have resulted from dangerous social conditions facing other minority or marginalized populations. African Americans and Latinx communities have suffered much higher rates of infection and death than predicted by their proportion in national or state populations. For instance, as of April 2020 in Illinois, 29 percent of confirmed COVID-19 cases and 41 percent of deaths occurred in people identified as African Americans, even though they comprised only 15 percent of the state’s population. Similarly, in Michigan, where 14 percent of the state’s population were African Americans, they accounted for 34 percent of confirmed cases and 40 percent of deaths. In the state of Washington, people identified as Latinx comprised 37 percent of confirmed COVID-19 cases, while the state’s population included only 13 percent of Latinx people.⁶

The reasons for these higher rates of infection and death are similar to those affecting the Navajo Nation and other indigenous communities: stressful living and working conditions associated with poverty, discrimination, inadequate food and housing, and associated diseases like diabetes, hypertension, and heart disease that increase risk. Members of these minority groups, including undocumented workers, must work to receive survival wages, and they often receive categorization as “essential workers” in meat-packing plants, agriculture, construction, custodial jobs, low-level health work in hospitals and nursing homes, and other jobs that make social distancing extremely difficult.

In social medicine, the visions of “upstream” and “downstream” help us understand causes and effects of important health problems at different levels of analysis.⁷ Inequalities of infection and death are “downstream” effects of “upstream” social conditions. These upstream conditions include poverty, discrimination, inadequate access to food and housing, unavailable clean water and sanitation, and similar challenges that play an important role in essentially all major epidemics in the past, present, and future. However, other important upstream causes of epidemics have arisen more recently during the last century through changes that human beings have created in our natural environments and in the industrial production of our food. In Chapter 3, we return to these upstream causes of the COVID-19 pandemic.

Another Outbreak: Typhus in Upper Silesia

Now let us turn back the clock to 1847 and consider the experience of a young German pathologist named Rudolf Virchow. ...