Sofia Weiss Goitiandia and Izzy Edwards
University of Cambridge
May 17, 2020
BJ Miller, a well-known US palliative care physician, said in his TED talk that “healthcare was designed with diseases, not people at its centre. Which is to say, of course, it was badly designed.” The radical expansion of our knowledge of and ability to manage disease has meant that modern medicine, and the doctors who are trained for it, can have tunnel-like vision into pathologies and their potential cures. Even those medical students and doctors who have a tendency, through nature or good teaching, to see patients as whole biopsychosocial entities might be missing something evident in the first line of the Declaration of Geneva: “I solemnly pledge to dedicate my life to the service of humanity.” As doctors, we are called to work not only to the benefit of our own patients, but of all human-kind.
To us, this means that exercising ‘social responsibility’ forms an integral part of the job of a doctor. In practice, this means doctors should learn about the population-level determinants of health and illness, and realise that our clinical practice should address these as central to disease rather than an afterthought. At the smallest scale, this could be educating ourselves on local housing, childcare or even hospital policy, in order to better advocate for the needs of marginalised individuals, by recognising the wider social factors that may be contributing to their particular experience of illness and healthcare. At the largest, it is involvement in national and international policy or activism. This is illustrated recently by Docs Not Cops, who are actively working against the ‘Hostile Environment’ towards migrants in the UK’s NHS, and Doctors for Camp Closure in the US, some of whom were recently arrested whilst attempting to administer flu vaccines to detained children at the border with Mexico. In the age of COVID-19, doctors have taken up various causes: some have been advocating for the public to stay inside; others have been speaking up on social media about the urgent need for PPE; still more have raised their voices about the need for any treatments for COVID-19, and particularly for any vaccine produced, to be fairly priced and accessible to all.
This vast, challenging nature of the issues to be addressed, and the breadth and depth of what can be done means that in practice, many people don’t know where they can start when thinking about how to bring social justice into healthcare.
We would advocate for beginning with the simple: one achievable, yet critically important, example of where we can make a difference is in considering our own prejudices. However good and fair we are, all of us have unconscious, preconceived biases about people we encounter day to day. These include biases around race, class, gender, sexual orientation, gender identity, disability and many others. For doctors, these can affect how much we listen to and believe a patient, and how we choose to talk to them.
Marginalised groups are known to seek healthcare later, less frequently and with more trepidation than the general population. With recent research in the LGBT+ community showing that a quarter (24%) of patient-facing staff have heard colleagues make negative remarks about lesbian, gay or bi people, and 20% have heard similar disparaging remarks about trans people, it is not hard to see why. Indeed, in a further study, 30.8% of transgender people reported delaying seeking healthcare for fear of discrimination, with those who reported having to educate their own healthcare provider on trans health being four times more likely to delay. The evidence is clear: even if we do not realise we are being insensitive, as a profession all too often we are driving away those who most need our help.
One action we can all take to tackle this issue is to start small and reflect upon our own biases: acknowledge that they are there, and particularly – as Marcelin et al., 2019 note – how often they can seem like “intuition”. We can question our assumptions about our patients and alter our behaviour accordingly, educate ourselves about social justice issues, and seek to understand why our biases might impact good healthcare delivery for our patients. Specifically, Phillips et al. (2016) suggest the practice of “deliberate reflection” as a simple tool for starting to effect these changes: before encounters that are likely to be affected by bias, doctors are encouraged to actively “consider the perspective of the individual whom they will be evaluating or interacting with and the potential impact of their biases on that individual.” Such practices can pre-emptively allow physicians to identify their own biases, and correct for them during the course of the interaction. In those cases where we unintentionally do act in a discriminatory manner, we should be encouraged to ‘own our actions’, discussing them with others and listening to people from marginalised groups, so that we can truly understand why our actions are damaging. We can then work to self-reinforce behaviours that will prevent those biases from affecting the care we give, again. These are not drastic changes, but they are a means by which individual action can make a positive difference. If combined with healthcare system leadership on this issue, for example, by providing bias training to all staff and appointing roles focused on putting health equity on the agenda, we stand to at least begin a revolution in trust and care, particularly for those marginalised groups who need it most.
Doctors stand to contribute at the level of institutions, too. For example, by becoming advocates for the integrated care of their patients, that is, care that “impose[s] the patient’s perspective as the organising principle of service delivery.” The evidence to date shows that a lack of integration within healthcare systems, – e.g., primary, secondary and tertiary levels of care – but especially between health and social care, means that “patients get lost, needed services fail to be delivered, or are delayed, quality and patient satisfaction decline.” Again, the actions to be taken by physicians to address this problem need not be Herculean. Byadvocating for service users, getting to know and working readily with our colleagues across different branches of health and social care, and by taking greater responsibility for the coordination of services, we ourselves can be agents for more integrated care. Some physicians may choose, in addition to this, to organise and venture into the political sphere, making clear to policy-makers the needs of the patients that they represent, to the end of formalising changes such as more integrated care services through political means. Getting involved in either type of advocacy, we contend, represents an engagement not only with the cause of social justice within our profession, but also with the practice of a more humanistic medicine: being, above all, there with and on behalf of the patient, and their needs. As Schattner has recently summarised, for the benefit of both patients and physicians themselves, “disseminating [such] principles of humanistic medicine is feasible and urgently needed.”
Finally, and on perhaps the most challenging scale, the role for social responsibility in medicine is exemplified by the climate crisis, which presents us with a bizarre conflict in the profession. The Lancet has named the climate crisis the single “greatest threat to public health in the 21st century”, highlighting that “without accelerated intervention, this new era will come to define the health of people at every stage of their lives”. The activism of global school strikers, Extinction Rebellion and grassroots movements in the Pacific Islands, Brazil and across Africa, has sensitised much of the public to the risks – health-related, and otherwise – of climate change. Yet it is easy to overlook that, actually, many healthcare systems are major emitters of CO2 and other greenhouse gases, as well as huge users of single use plastics. Indeed, a surgery such as a hysterectomy can produce over nine kilograms of waste per procedure, most of which is non-disposable plastic, whilst it is estimated that the healthcare sector ranks, in absolute terms, as the world’s fifth largest emitter of greenhouse gases.
We know that deaths due to drought, food shortages and extreme weather are happening already because of climate breakdown, and that if current trends continue into the future, vulnerable populations, as well as low- and middle-income countries are likely to be the worst affected. It is clear too that our profession is contributing. So, what on earth are we supposed to do? Where does our social responsibility lie here?
We cannot stop treating our patients, and we cannot abandon humanity to suffer climate and ecological collapse. However, we can use social activism to push for a system that allows us to treat both. A system that recognises that the increase in children presenting to us with asthma may be linked to pollution, and that fuel poverty in winter and extreme heat in summer bring people to our emergency departments. Within the past year, doctors have already been taking to the streets to protest the level of inaction on this issue, some taking part in marches, sit ins, citizens assemblies, giving educational talks and taking part in Non-Violent Direct Action (NVDA) to stand up for their patients’ right to a liveable planet. One powerful example has been a group of 30 doctors who protested in London in September 2019, attempting to provoke action on climate change. Four of them were arrested for “gluing-on” to government buildings, viewing it as their responsibility to use their privileged position to advocate for others. Even Richard Horton, editor of the Lancet, has come out in support of NVDA owing to the seriousness of this crisis. Further, since 2019 “Doctors for Extinction Rebellion” groups have been appearing worldwide. These are groups of individuals who care deeply about their patients, and are – in line with the Declaration of Geneva – standing up to protect humanity from an existential threat, that no medicine or surgery can solve. They speak of it not as a choice, but as their duty as clinicians.
As many argue, with a prediction of just 11 years from 2018 to prevent a catastrophic 1.5 degrees of warming, this is the time for action. Our profession would be unwise to pretend that healthcare is an ivory tower: we must accept that we contribute to the problem, and we must work together towards solutions. Using some of the techniques described to lobby for policy changes both within and beyond healthcare is certainly one way to start doing so.
From worldwide campaigns for female suffrage, to individuals like Harvey Milk and wider advocacy for LGBT rights, to 2019’s “y la culpa no era mía” movement from Chile to the world, our planet continues to be a more equal and inclusive place for the successes of social activism. Medicine has hugely benefitted thus far: we can think to the days of John Snow and Florence Nightingale and their lasting influence on the field, to more recent examples such as Dr Denis Mukwege in the DRC and his campaign against rape as a weapon or war, or of the success of the Treatment Action Campaign, in achieving equitable access to HIV/AIDS medicines in South Africa. These people’s sense of social responsibility and subsequent activism were not peripheral to their medical practice, but integral parts of it. We argue that they are models to be followed.Social activism is a valid, legal and proportionate treatment for the social problems that lead to the diseases that doctors the world over are seeing in their consulting rooms. Yet doctors who take stands on population-level issues are often ignored, or viewed as overly political. Let us be clear: there is nothing political about challenging a system that contributes to homelessness, malnutrition, depression, and a plethora of other diseases. There is nothing political about wanting the best for humanity.