Activism in Medicine History Literature and Contemporary Issues

Activism in Medicine: History, Literature, and Contemporary Issues and Movements Martin Donohoe

Overview Background Issues History Literature Quotes and Photos Education, the media, and democracy What you can do

Portland, Oregon Mount Hood

Multnomah Falls, Oregon

Am I Stoned? A 1999 Utah anti-drug pamphlet warns: “Danger signs that your child may be smoking marijuana include excessive preoccupation with social causes, race relations, and environmental issues”

Harvey Cushing “A physician is obligated to consider more than a diseased organ, more even than the whole man. He must view the man in his world. ”

Medicine and Public Health Schism between the fields Witnessed victims vs. “statistical” victims Precautionary Principle

Important Contributions of Public Health Water and food safety Sanitation Vaccination Fluoridation Iodine supplementation of table salt Seat belts, air bags Bed nets for malaria prevention Barriers to decrease bridge suicides

Reasons for Underfunding of Public Health (NEJM 362; 18: 1657 -8) Benefits of public health programs lie in the future Beneficiaries of public health measures are generally unknown Benefactors are often unknown Opposition to public health programs often political, corporate Medical care usually promoted by corporate interests

Important Historical Figures in Medicine/Public Health and Social Justice Florence Nightingale Clara Barton Margaret Sanger Thomas Hodgkin Albert Schweitzer Rachel Carson Lois Gibbs

Important Historical Figures in Medicine/Public Health and Social Justice Charles Dickens Anton Chekhov Upton Sinclair George Orwell William Carlos Williams

Rudolph Virchow Founder of modern pathology Thrombosis, pulmonary embolism, leukocytosis, leukemia Member of state and local government for over 30 years Founded journal Medical Reform

Rudolph Virchow Argued that many diseases result from “the unequal distribution of civilization’s advantages” Advocated public provision of medical care for the indigent Promoted universal education

Rudolph Virchow Worked to outlaw child labor Improved water distribution and sewage system Enhanced food inspection process Published study of skull volumes to dispute myth of larger Aryan brains

Rudolph Virchow Passed hygiene standards for public schools Set new standards of training for nurses Improved local hospital system

Rudolph Virchow “Doctors are natural attorneys for the poor … If medicine is to really accomplish its great task, it must intervene in political and social life…”

Issues Access to care Boutique medicine Racial, sexual and SES discrepancies in outcomes Homelessness Effects of poverty on health Hunger

U. S. Health Care Per capita expenditure on health care: U. S. = $9, 255 Typical poor African/Asian country = $550 Even so, U. S. had 42 million uninsured (36 million post PPACA), ranks 24 th worldwide in overall population health as judged by disability-adjusted life expectancy

Headline from The Onion Uninsured Man Hopes His Symptoms Diagnosed This Week On House

Racial Disparities in Health Care: African-Americans Higher maternal and infant mortality Higher death rates for most diseases Shorter life expectancies Less health insurance Undergo fewer diagnostic tests / therapeutic procedures

Racial Disparities in Health Care: African-Americans Equalizing the mortality rates of whites and African-Americans would have averted 686, 202 deaths between 1991 and 2000 Whereas medical advances averted 176, 633 deaths AJPH 2004; 94: 2078 -2081

Social Factors Responsible for Illness and Deaths in 2000 attributable to: Low education: 245, 000 Racial segregation: 176, 000 Low social support: 162, 000 Individual-level poverty: 133, 000 Income inequality: 119, 000 (population-attributable mortality – 5. 1%) Area-level poverty: 39, 000 (population-attributable mortality – 1. 7%) AJPH 2011; 101: 1456 -1465

Deaths per year Tobacco = 400, 000 (+ 50, 000 ETS) Obesity = 300, 000 Alcohol = 100, 000 Microbial agents = 90, 000 Toxic agents = 60, 000 (likely higher) Firearms = 35, 000 Sexual behaviors = 30, 000 Motor vehicles = 25, 000 Illicit drug use = 20, 000

Diseases Responsible for Illness and Deaths in 2000 attributable to: AMI – 193, 000 CVD – 168, 000 Lung CA – 156, 000 AJPH 2011; 101: 1456 -1465

Issues Excessive pharmaceutical company influence, dubious marketing practices Women’s rights issues: Violence against women Access to reproductive health care Female genital cutting Political, legal, and educational marginalization

Status of Women Economic discrimination Women do 67% of the world’s work Receive 10% of global income Own 1% of all property A woman in a developing country walks an average of 6 km/day to obtain water

Issues Environmental degradation Overpopulation Air and water pollution Toxins Deforestation Global warming

Issues Environmental degradation Unsustainable agricultural and fishing practices Famine Commodification of world’s food and water supply by corporations Species loss

Poverty and Inequality in the U. S. 14% of adults and 21% of children live in poverty Food insecurity common Gap between rich and poor widening, largest of any industrialized nation

Poverty Worldwide 650 million people lack access to safe, clean drinking water 2 billion have no electricity 2. 3 billion do not have adequate sanitation services Hunger kills 18, 000 people per day, most under age 5 1. 8 million child deaths/year

Consequences of Pollution Causes 200, 000 premature deaths/yr. in U. S. (8. 9 million worldwide = 1/8 deaths) NAS: Pesticides in food could cause up to 1 million cancers in the current generation of Americans

Air Pollution

Air Pollution

Toxic Exposures 13, 000 -15, 000 deaths per day worldwide from water-related diseases In developing countries, 90 -95% of sewage and 70% of industrial wastes are dumped untreated into the local water supply 1 in 4 U. S. citizens lives within 4 miles of a Superfund site Lead and mercury exposure multi-billion dollar problems

Water Pollution: Bathtub=Toilet=Source of Drinking Water

Toxins: Minimata Disease - W Eugene Smith

Deforestation

Greenland’s Ice Cap Melting: 1992

Greenland’s Ice Cap Melting: 2002

Greenland’s Ice Cap Melting: 2005

Climate Change: Drought

Famine

Factory Farms # 1 polluters of American waterways Agriculture accounts for 70% of U. S. antibiotic use #1 contributor to food-borne, antibioticresistant infections (CDC) Source of MRSA, other resistant bacteria

Factory Farming

Overfishing: Factory Trawlers

Dynamite Reef Fishing

Species Loss = Lost Pharmacopoeia Drugs from plants and native peoples’ health knowledge More than 1/2 of the top 150 prescription drugs contain an active compound derived from or patterned after natural products -e. g. digoxin, vincristine, paralytic agents, etc. Of the more than 250, 000 known flowering species, <0. 5% have been surveyed for medicinal value

A Cure for Cancer?

Social Justice Issues Maldistribution of wealth Overconsumption (“affluenza”) Rise of the corporation 53 of the world’s 100 largest economies are private corporations; 47 are countries Minimum wage ≠ Living wage Third World debt crisis Human rights abuses

Maldistribution of Wealth U. S: Richest 1% of the population owns 50% of the country’s wealth; poorest 90% own 30% Widest gap of any industrialized nation

Maldistribution of Wealth Less than 4% of the combined wealth of the 225 richest individuals in the world would pay for ongoing access to basic education, health care, adequate food, safe water, and adequate sanitation for all humans (UNDP)

Overconsumption (“Affluenza”) U. S. = 4. 5% of world’s population Owns 50% of the world’s wealth U. S. responsible for: 25% of world’s energy consumption 33% of paper use 72% of hazardous waste production

George Orwell “Some people are more equal than others”

Hudson River, 2009

Voltaire “The comfort of the rich rests upon an abundance of the poor”

Primo Levi “A country is considered the more civilized the more the wisdom and efficiency of its laws hinder a weak man from becoming too weak or a powerful one too powerful. ”

Issues War and Militarism: Diversion of economic resources and intellectual capital Prejudice/hate crimes Erosion of civil liberties Weapons of mass destruction Military = world’s largest polluter

The Military: Diversion of Resources Away from Health Care 3 hours world arms spending = annual WHO budget 1/2 day of world arms spending = full childhood immunizations for all world’s children 3 weeks of world arms spending/yr. = primary health care for all in poor countries, incl. safe water and full immunizations “War on Terror” creating enormous U. S. debt

War and Peace World military budget = $1. 8 trillion in 2012 230 times what the UN spends on peacekeeping US: Largest military budget, largest arms supplier Greatest debtor to UN peacekeeping fund

“Every gun that is made, every warship launched, every rocket fired, signifies in the final sense a theft from those who hunger and are not fed, those who are cold and not clothed. ” ~ Dwight D. Eisenhower

“The problem in defense spending is to figure out how far you should go without destroying from within what you are trying to defend from without. ” ~Dwight D. Eisenhower

Discretionary Federal Spending (2013)

World Military Spending (2012)

Kuwaiti Oil Fires – Gulf War I

The Value of the History of Medicine Provides context for contemporary practices Promotes pride in our field and sense of mission to carry on work of our predecessors Fosters humility regarding utility of novel technologies

Brigham and Women’s Hospital Established 1966 through merger of Peter Bent Brigham Hospital, Robert Breck Brigham Hospital, and Boston Hospital for Women 1847: First administration of anesthesia in childbirth

Brigham and Women’s Hospital: History 1913: Harvey Cushing named surgeon-inchief Father of modern neurosurgery Used X-rays to diagnose brain tumors, electrical stimuli to study sensory cortex Helped develop Bovie electrocautery Discovered Cushing’s Disease

Brigham and Women’s Hospital: History 1923: Elliott Cutler performs world’s first successful heart valve surgery 1926: William Murphy, George Whipple, and George Minot discover that liver extracts cure pernicious anemia Awarded Nobel Prize 1939: Soma Weiss named physician-in-chief – co-discoverer of Mallory-Weiss tears

Brigham and Women’s Hospital: History 1949: first use of cortisone for rheumatoid arthritis 1949: Carl Walter develops world’s first blood bank 1954: Joseph Murray performs first successful human organ (kidney) transplant Awarded Nobel Prize

Brigham and Women’s Hospital: History 1962: D/C cardioversion used for first time to restore normal heart rhythm in A-fib Home of first CCU Today: one of the largest non-university recipients of research funding from NIH Contemporary leaders in medicine

The Role of Literature Vicarious experience Explore diverse philosophies Promotes empathy, critical thinking, flexibility, non-dogmatism, self-knowledge Encourages creative thinking Allows for group discussion/debate

Why Use Literature Encourage appreciation of non-medical literature Develop reading, analytical, speaking and writing skills Promote ethical thinking (narrative ethics) Identification with doctor authors (e. g. , Keats, Chekhov, Maugham, Williams) Can be used in a variety of settings

Homelessness Doris Lessing “An Old Woman and Her Cat” From the Doris Lessing Reader (New York: Knopf, 1988)

Race and Access to Care Ernest J Gaines “The Sky is Gray” in Gray, Marion Secundy, ed. Trials, Tribulations, and Celebrations: African American Perspectives on Health, Illness, Aging and Loss. Yarmouth, Maine: Intercultural Press, 1992

Poverty Orwell, George. How the Poor Die. In Sonia Orwell and Ian Angus, eds. The Collected Essays, Journalism and Letter of George Orwell, IV; In Front of Your Nose, 1945 -1950. New York: Harcourt, Brace and World, Inc: pp. 223 -233. Checkhov, Anton. Letter to AF Koni, January 26, 1891, Letter to AS Survivor, March 9, 1890. In Norman Cousins, ed. The Physician in Literature Philadelphia: WB Saunders, 1982.

Impediments to Public Health and Social Justice Political climate Scientific Ignorance Pseudoscience Damaged educational system The corporate media All lead to the decline of democracy

Bush Administration Key administrators/committee members/regulators former industry representatives and/or lobbyists Privatization of public services Corporate profit before public good Unsound/distorted/suppressed science

Bush Administration Rollbacks of key environmental laws Lax enforcement of existing laws Huge tax cuts primarily benefit wealthy Federal and state government deficits astronomical Program and funding cuts Increased trade deficit Obama – ? change?

Obama Administration Large industry influence Very slow progress

Would You Sign a Petition to Ban Dihydrogen Monoxide? 1. It can cause excessive sweating and vomiting 2. It is a major component in acid rain 3. It can cause severe burns in its gaseous state 4. It can kill you if accidentally inhaled 5. It contributes to erosion 6. It decreases effectiveness of automobile brakes 7. It has been found in tumors of terminal cancer patients

Environmental and Geographic Ignorance A majority of Americans believe that electricity in the U. S. is produced in nonpolluting ways 25% knew that majority (70%) comes from oil, coal and wood Percent of US teens unable to locate the following on a map: United States – 11% Pacific Ocean – 29% Japan – 58%

Pseudoscientific Beliefs Percentage of Americans who believe “at least to some degree” in these “phenomena” 1997 Astrology (35%, 2014) 37% UFOs 30% Reincarnation 25% Fortune-Telling 14% 1976 17% 24% 9% 4%

Ignorance/Pseudoscientific Beliefs Half of US citizens do not believe in evolution and do believe that humans and dinosaurs coexisted (2007) 40% think scientists still generally disagree about evolution Only 12% of U. S. Protestant pastors believe in evolution 70% believe in global warming

Pseudoscientific Beliefs 37% believe places can be haunted (2007) 25% believe in UFOs (2007) 24% believe in astrology (2009) 16% believe that people with the “evil eye” can cast curses or harmful spells Widespread misconceptions regarding vaccine efficacy and safety and antibiotic use/resistance

Pseudoscientific Beliefs 22% of Americans don’t know whether an atomic bomb has ever been dropped (2000) 20% of Americans don’t know the earth revolves around the sun (1999) 18% believe in Bigfoot and the Loch Ness Monster (2007) 8% of men / 18% of women believe in astrology and fortune tellers (2007) 14% have consulted a psychic or fortune teller (2009)

Obfuscating Influence of Religion Onion Headline:

Greenwash Public relations / ad campaigns Chevron’s “People Do” Campaign, butterflies/refinery Grants to a few scientists who challenge environmental warnings Tobacco ads in 1950’s

Astroturf Artificially-created grassroots coalitions Corporate front groups: The American Council on Science and Health National Wilderness Institute The Foundation for Clean Air Progress

Corporate-sponsored environmental education materials (examples) Exxon’s “Energy Cube” -“Gasoline is simply solar power hidden in decayed matter” -“Offshore drilling creates reefs for fish” Pacific Lumber Company -“The Great American Forest is. . . renewable forever”

Sponsored Environmental Education Materials (Examples) International Paper -“Clearcutting promotes growth of trees that require full sunlight and allows efficient site preparation for the next crop” American Nuclear Society’s “Activities with the Atoms Family” Dow’s “Chemipalooza”

Textbook Publishers Facilitate Corporate Messaging Scholastic, Inc. World’s largest publisher of children’s educational materials Found in 90% of U. S. classrooms Has taken money from Big Coal, Disney, Microsoft, Nestlé, and Shell to produce books and lesson plans 2011: Announces plan to terminate some industry contracts, set up quasi-independent review board to review corporate materials

Advertising “Doubt is our product” Brown and Williamson Tobacco Company Memo, 1960 s

Advertising US now spends $290 billion/yr on advertising Almost $1, 000/person/yr in the U. S. 10% of a two-year olds nouns are brand names The average American recognize over 1, 000 corporate logos, but fewer than 10 plants and animals native to his/her locality

Television The average American youth spends 900 hrs/yr in school, 1, 500 hrs/yr watching TV Average teen spends 9 hrs/d on social media By age 65, the average American will have spent 9 yrs watching TV Contributor to obesity epidemic

Public Education in Disarray U. S. Schools ranked lowest among western nations ↓ funding, infrastructure decaying 1/4 of U. S. Schools have no library

Public Education in Disarray Inadequate funding, decaying infrastructure National HS graduation rate 65 -70% No change from 1970 s Lower incomes youths 6 X as likely to drop out ¼ of Americans functionally illiterate

Public Education in Disarray College tuition costs rising, state funding decreasing Increasingly marginalizes poor, minorities 70% of students come from wealthiest ¼ of US families 14% from the poorest half But 39% of highest-achieving students from poorest half

Benefits of Education For every $1 spent on early childhood education, up to $17 are saved from increased school achievement, improved health, reduced crime, and reduced reliance on public assistance Income increases 11% for every year of education

Benefits of Education College graduates live 5 years longer than high school dropouts Eliminating educational inequities would have saved 8 X as many lives as medical advances from 1996 -2002

Ignorance vs. Democracy “Information is the currency of democracy” Thomas Jefferson

The Media Most media organizations owned by multinational, multi-billion dollar corporations that are involved in a number of businesses apart from the media, such as forestry, pulp and paper mills, defense, real estate, oil wells, agriculture, steel production, railways, and water and power utilities

Global Warming: Controversial? Of 928 articles in peer-reviewed scientific journals, 0% were in doubt as to the existence or cause of global warming Of 636 articles in the popular press (NY Times, Washington Post, LA Times, WSJ), 53% expressed doubt as to the existence (and primary cause) of global warming Science 2004; 306: 1686 -7 (Study covers 1993 -2003)

Global Warming Global warming: 400, 000 deaths and 5. 0 - 5. 5 million disability-adjusted life years lost per year (Climate Vulnerability Monitor, WHO, UN Environment Program) Expected to double by 2030 Weather extremes

Lobbying Almost 12, 000 full-time lobbyists Estimates of return on lobbying range from $28 to $212 for every $1 spent (higher values more likely) Return on campaign contributions for elections for the most politically active companies = $760 per $1 spent

Lobbying Revolving door between lobbyists and Congress Between 2001 and 2011, 5, 400 former Congressional staffers left to become lobbyists, and 605 lobbyists left their positions to work for Congress

Lobbying Pharmaceutical/health products lobby spent $230 million lobbying in 2014 (more than any other industry) 2. 3 for every member of Congress The pharmaceutical industry is the biggest defrauder of the federal government It has paid out almost $20 billion in civil and criminal penalties over the last 20 years

Lobbying/Campaign Contributions Koch brothers spent over $400 million (2012) All single issue ideological groups combined (e. g. , pro-choice, anti-abortion, feminist and consumer organizations, senior citizens, etc. ) = less than $100 million (2012) Lobbying groups spent 3. 2 billion in 2014

Political Spending Corporations vs. Labor U. S. Chamber of Commerce spent $85 million on Congressional elections (2012); $85 million on lobbying in 2015 CEO Tom Donahue highest-paid corporate trade group chief AFL-CIO and SEIU (two largest labor unions) spend $6 million combined

The “Benefits” of Sterility-Causing Chemicals in the Workplace? 12 September 1977 Dr. Eula Bingham, Assistant Secretary for Occupational Safety and Health [Regarding] worker exposure to DBCP. While involuntary sterility caused by a manufactured chemical may be bad, it is not necessarily so. After all, there are many people who are now paying to have themselves sterilized to assure they will no longer be able to become parents. . . If possible sterility is the main problem, couldn’t workers who were old enough that they no longer wanted to have children accept such positions voluntarily? Or…some [workers] might volunteer for such workposts as an alternative to planned surgery for a vasectomy or tubal ligation, or as a means of getting around religious bans on birth control when they want no more children? Sincerely, Robert K. Phillips, National Peach Council

The Decline of Democracy True democracy demands an informed citizenry (education), freedom of the press (media), and involvement (will, time, money)

What you can do Explore the history of medicine Respect Question dogma: “The least questioned assumptions are often the most questionable” – Paul Broca Read great literature Patients illnesses are stories Take patient’s perspective Develop a public health-oriented perspective in care of patients Find your passion

What you can do Become active in an organization Educate yourself Educate your students and your patients Use the media Volunteer, do pro bono work Satisfies your debt to society Feeds your soul

The health impact pyramid Frieden, T. R. Am J Public Health 2010; 100: 590 -595 Copyright © 2010 American Public Health Association

Contemporary Activist Organizations Physicians for Social Responsibility, Physicians for Human Rights, Amnesty International Union of Concerned Scientists, Public Citizen’s Health Research Group PNHP, Doctors without Borders, Doctors for Global Health Greenpeace, Sierra Club, HCWH, NRDC, ED, No Dirty Gold, PANNA Planned Parenthood, NARAL Others

African Proverb If you think you are too small to have an impact, try going to bed with a mosquito in your tent

“First they came for the Jews” by Pastor Niemoller “First they came for the Jews, and I did not speak up, for I was not a Jew. Then they came for the communists, and I did not speak up for I was not a communist. Then they came for the trade unionists, and I did not speak up, for I was not a trade unionist. Then they came for me, and there was no one left to speak up for me. ”

Contact Information Public Health and Social Justice Website http: //www. phsj. org martindonohoe@phsj. org