Social Justice in Medicine Perspectives from History Literature

Social Justice in Medicine: Perspectives from History, Literature, and Photography Martin Donohoe

Perspective The earth spins at 1, 038 mph at the equator, between 700 mph and 900 mph at midlatitudes The earth rotates around sun at 18. 5 miles/sec The solar system orbits the center of the Milky Way Galaxy at 137 miles/sec One rotation per 225 million years

Perspective The sun is one of hundreds of billions of stars in the Milky Way Galaxy The Milky Way is one of over one hundred billion galaxies in the known universe The universe may be one of an infinite number of universes

The Planets

Our Solar System

Jupiter = one pixel, Earth = invisible

Sun = one pixel, Jupiter = invisible

Our Home

Earth/Moon Seen by Voyager Spacecraft through Saturn’s Rings

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. ”

Martin Luther King, Jr. “Injustice anywhere is a threat to justice everywhere”

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

Important Historical Figures in Public Health and Social Justice Dr. Thomas Hodgkin (abolitionist and opponent of British oppression of native populations in South Africa and New Zealand) Nurse Margaret Sanger (founder of the family planning movement in the US) Dr. Albert Schweitzer (won Nobel Peace Prize in part for developing a missionary hospital for the poor in Gabon, Africa)

Important Historical Figures in Public Health and Social Justice Florence Nightingale (feminist, founder of the modern nursing profession, and advocate for hygienic hospitals) Dr. Salvador Allende (assassinated president of Chile and promoter of better living conditions for the poor and working classes). *The quiet and unknown*

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…”

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

Why Study Literature? “Why live? Life without literature is reduced to penury. It expands you in every way. It illuminates what you’re doing. It shows you possibilities you haven’t thought of. It enables you to live the lives of other people…It broadens you, it makes you more human. It makes life more enjoyable. ” M. H. Abrams

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

U. S. Health Care Per capita expenditure on health care = $9, 255 Typical poor African/Asian country = $550 28 million uninsured 29, 000 deaths/yr Health outcomes poor

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

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.

Jacob Riis

Dorothea Lange

Poverty and Inequality in the U. S. US: 15% of residents and 22% 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. 3 billion do not have adequate sanitation services Hunger kills 18, 000 people per day, most under age 5

James Nachtwey

Maldistribution of Wealth Richest 1% own 46% of the world’s wealth Top 85 billionaires worldwide worth $1. 7 trillion, the combined income of bottom 3. 5 billion people (1/2 of world’s population)

Maldistribution of Wealth U. S: Richest 1% of the population owns 40% of the country’s wealth -poorest 90% own 30% -widest gap of any industrialized nation

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

Income Inequality Lower life expectancy Higher rates of infant and child mortality Short height Poor self-reported health AIDS

Income Inequality Depression Mental Illness Obesity Crime Diminished trust in people and institutions (↓ social cohesion/happiness)

Maldistribution of Wealth is Deadly 880, 000 deaths/yr in U. S. would be averted if the country had an income gap like many Western European nations, with their stronger social safety nets BMJ 2009; 339: b 4471

Declaration of Independence Thomas Jefferson “All men are created equal”

George Orwell “Some people are more equal than others”

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

Hudson River, 2009

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. ”

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

Rachel Adams

Homeless 3 million homeless (13 -17% of homeless adults work) 7% lifetime prevalence Combined income of 10 richest American’s could pay one year’s rent for every homeless person

Women’s Rights Violence against women Access to reproductive health care Female genital cutting Political, legal, and educational marginalization Women do 67% of the world’s work Receive 10% of global income Own 1% of all property

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

Toxins: Minimata Disease - W Eugene Smith

Wars and Human Rights Abuses 250 wars in 20 th Century World military budget = $1. 8 trillion in 2012 US - largest military budget, largest arms supplier Greatest debtor to UN peacekeeping fund Non-cooperation viz a viz international agreements

Colonial Exploitation Christopher Columbus’ log entry upon meeting the Arawaks of the Bahamas: “They…brought us…many…things…They willingly traded everything they owned…They do not bear arms…They would make fine servants…With fifty men we could subjugate them all and make them do whatever we want. ”

Colonial Exploitation Cecil Rhodes (Rhodesia, Rhodes Scholarship, De. Beers Mining Company): “We must find new lands from which we can easily obtain raw materials and at the same time exploit the cheap slave labour that is available from the natives of the colonies. The colonies would also provide a dumping ground for the surplus goods produced in our factories. ”

War Wars often fueled by battles over natural resources: Land Water Gold, diamonds, rare earth metals

Sebastiao Salgado

Sebastiao Salgado

Sebastiao Salgado

Sebastiao Salgado

Sebastiao Salgado

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

“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

Impediments to Public Health and Social Justice Scientific Ignorance Pseudoscience Damaged educational system The corporate media/media consolidation All lead to the decline of democracy “Information is the currency of democracy” (Thomas Jefferson)

Recommendations for Medical Education and Practice Increased focus on the patient (bedside teaching, patient education) Increased chart note quality Most notes now templated, clinically important items buried in morass of cut-and-pasted gobbledygook Individual patients’ stories lost Decrease disparities in pay between generalists and subspecialists; increase pay for cognitive work

Recommendations for Medical Education and Practice Improve prevention, identification, and treatment of mental illness and burnout Greater attention to public health and social justice Increased focus on the arts and humanities, including the rich history of medicine

What you can do Explore the history of medicine Read great literature Patients illnesses are stories Develop a public health-oriented perspective in care of patients Find your passion

Work Together “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has. “ - Margaret Mead

Speak Up for the Disenfranchised “The first job of a citizen is to keep your mouth open. ” - Günter Grass

“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. ”

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

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