FESTSCHRIFT IN HONOR OF DR. VICTOR SIDEL

Social justice: The heart of medical education

Allen L. Hixon,MD; Seiji Yamada,MD, MPH; Paul E. Farmer, MD, PhD; Gregory G. Maskarinec, PhD

Abstract the social determinants of health, to advocate for Building on the long-standing institution of the equitable change, and to advance so- Hippocratic Oath, the authors suggest that all physi- cial justice throughout their careers should be the cians-in-training must be taught the principles af- focus of this training. As this training prepares lead- firmed by the 1978 Declaration of Alma-Ata. Physi- ers to press for system change in the U.S., it also cians should recognize that health is a fundamental aligns with the global trend of recognizing human human right and that gross inequalities in health rights as a core competency of medical education. care are unacceptable for moral, political, social, and economic reasons. Incorporating an explicit fo- Roots and definition of “social justice” cus on social justice in medical education will lead In medicine, we define “social justice” as equali- to the training of physicians who understand that to ty in access to and quality of health care and the advance the goal of “health for all” they must work right to health of everyone.1 This definition recog- toward more equitable distribution of health care nizes, as the Declaration of Alma-Ata identified and the elimination of health disparities, both within more than 30 years ago, that gross inequalities in the U.S. and internationally. Learning to understand health status are politically, socially, and economi- cally unacceptable and that health is a fundamental human right.2 Allen L. Hixon, MD Professor and Chair The modern concept of social justice in health Department of Family Medicine and derives from 19th century social medicine, whose John A. Burns School of Medicine founder said, “The physician is the University of Hawai‘i natural advocate of the poor,” adding that “medicine

Seiji Yamada, MD, MPH has imperceptibly led us into the social field and (corresponding author) placed us in a position of confronting directly the Associate Professor great problems of our time.”3 Department of Family Medicine and Community Health While concepts of individual justice focus on an John A. Burns School of Medicine University of Hawai‘i individual’s rights and obligations within an orga- 95-390 Kuahelani Avenue nized state, the tenets of social justice expand these Mililani, HI 96734 rights and obligations to include the responsibilities Email: [email protected] of society to its members and its members’ respon- Fax 808-627-3262 4 sibilities to each other. Equity demands that similar Paul E. Farmer, MD, PhD cases be treated alike: for there to be equity in medi- Kolokotrones University Professor cine, patients with similar conditions must be enti- Harvard University; tled to similar treatment without regard to their eco- Chair, Department of and Social Medicine, Harvard Medical School nomic status, income, gender, ethnicity, or other social factors. To achieve this, treatment may need Gregory G. Maskarinec, PhD to address the unique socioeconomic situations that Associate Professor 5 Department of Family Medicine and Community Health have led to the condition. A commitment to social John A. Burns School of Medicine, justice requires that we not limit our sense of justice University of Hawai‘i simply to the more equitable provision of health

Social Medicine (www.socialmedicine.info) - 161 - Volume 7, Number 3, October 2013 care to those who are ill, but demands that we exam- “systems-based practice,” but which are crucial to ine injustices in the distribution of health and the the practice of medicine that recognizes health as a underlying reasons for unjust burdens of illness. basic human right. Social justice training fosters an appreciation of The importance of social justice to the future of how medicine fits into national and international medical care becomes evident if we examine some political economies, and emphasizes that combating of the critical issues now facing U.S. health care: (a) the social forces that create and enforce poverty is high costs leading to restricted access to care8; (b) necessary to improve the health of all of the world’s inadequate attention to prevention9; (c) reimburse- citizens.6 The historical roots of a social justice per- ment schemes that reward intervention and large spective in the practice of medicine provide a back- numbers of procedures at the expense of engaged, ground for understanding recent trends shaping the thoughtful analysis of problems; (d) poor care environment and the educational re- health outcomes, including racial and socioeconom- sponse to it. These include, inter alia, understanding ic disparities10; (e) improper distribution of specialty health disparities, cross-cultural health care, work- versus primary care11; (f) a growing imbalance in force diversity, , community-oriented rural/urban health care; and (g) an increasing popu- primary care, and global health. lation of the uninsured, including children.12 (Of the 48.6 million Americans without health insurance in How social justice training moves beyond “pro- 2011, 7.0 million were children.13) fessionalism” or “systems-based practice” Social and economic forces are not incidental to Physicians are required to make bioethical judg- medical education: they delineate the face of the ments in the context of basic human rights as an profession. Many contemporary global issues— integral part of their daily work with patients and including the HIV/AIDS pandemic and the close families, yet few medical schools systematically interaction between biomedical research and the teach human rights and their relationship to bioeth- —require us to inculcate a ics.7 Two current graduate competencies introduced philosophical orientation that will help learners and by the Accreditation Council for Graduate Medical practicing physicians recognize and respond ethical- Education (ACGME), “professionalism” and “sys- ly to challenges inherent to healthcare delivery. One tems-based practice,” do require physician engage- such challenge is the transnational distribution of ment with the broader health care system. “Profes- the health workforce. Writing in 2005, Mullan noted sionalism” addresses ethical principles that grow that international medical graduates constituted 23% largely out of clinical practice and the patient- to 28% of physicians in the United States, the Unit- physician relationship, including , ed Kingdom, Canada, and Australia, and lower- patient confidentiality, and the fiduciary duties of income countries supplied 40% to 75% of these in- physicians to patients. While fundamental to good ternational medical graduates, reducing the supply care, this competency falls short of a view of medi- of physicians in many lower-income countries.14 cine that encompasses its role in the betterment of Meanwhile, like medical education in the U.S., “too the society at large. The “systems-based practice” much conventional international competency encompasses the wider context of clini- shrinks from acknowledging the social roots of gro- cal practice, including communicating effectively tesque inequalities.”15 with the various members of the health care team. But no competency focuses on ensuring the equita- Social medicine ble distribution of health resources, understanding As a prescription for the ills of the current health the social determinants of health, recognizing injus- care system, we recommend wider adoption of the tice within health institutions such as hospitals or materials and methods of social medicine. Social clinics, or advocating for positive changes in the medicine studies the health of collective groups of larger health care system and in society—issues that people along with the power relationships between remain unaddressed by either “professionalism” or those groups and the institutions that impact their

Social Medicine (www.socialmedicine.info) - 162 - Volume 7, Number 3, October 2013 health. Social medicine looks historically at the root The Declaration of Alma-Ata causes of health and disease and promotes advocacy The Declaration of Alma-Ata,22 issued at the and activism. It attempts to counter reductionist ap- 1978 International Conference on Primary Health proaches common to the current practice of medi- Care by the World Health Organization (WHO) and cine, which often reduce medical care to efficient the United Nations Children’s Fund, reaffirmed the business practices and treat disease as though only WHO definition of health as “a state of complete isolated organ systems of sick individuals are in- physical, mental and social wellbeing, and not mere- volved.16 ly the absence of disease or infirmity.”23 It recog- As Rudolf Virchow put it: “Do we not always nized health care as a fundamental human right. find the diseases of the populace traceable to defects Gross inequalities in health care were proclaimed as in society?”17 Physicians must continue to seek and politically, socially, and economically unacceptable, remedy “defects in society” if health is to be recog- and it was affirmed that primary health care (PHC) nized as a basic human right. As the introductory should be universal as the key to improving health editorial in the journal Social Medicine observed, and reducing inequalities in health status. A multi- sectoral approach and community involvement em- [T]he social problems of the contemporary phasizing health as a positive state were central fea- world walk into the clinician’s office every day. tures of the PHC strategy, as was an emphasis on The mundane details of the social determinants .24 The WHO’s Health for All by 2000 of health are writ small in our daily encounters initiative was expected to be funded through de- with patients.18 creased military spending—a hoped-for develop- Many practicing physicians may gradually realize ment that has not yet occurred. this on their own; requiring training in social justice would help ensure that physicians seek to remedy The social determinants of health these sources of ill health. As defined by the WHO,

Salvador Allende, a physician and early promot- The social determinants of health are the condi- er of social medicine in Latin American, identified tions in which people are born, grow, live, work Chile’s subordinate role in the global system of pro- and age, including the health system. These cir- duction and exchange as the basis for the poor cumstances are shaped by the distribution of 19 health of its people. As president of Chile, he money, power and resources at global, national sought to limit the role of multinational corpora- and local levels25 tions. For his pains, he became a victim of regime change. … which is itself influenced by policy choices. “The In attempting to understand and correct the social determinants of health are mostly responsible mechanisms of social injustice and structural vio- for health inequities—the unfair and avoidable dif- lence, and articulating an explicit “preferential op- ferences in health status seen within and between 25 tion for the poor,” the Liberation Theology move- countries.” The social determinants of health in- ment in Latin America has exerted an influence on clude, on the one hand, access to clean water and the direction of Latin American Social Medicine.20 , food security, gender equality, economic and social security, and access to appropriate health Unlike most previous theologies, unlike much care resources—and, on the other hand, internation- modern philosophy, liberation theology attempts al sanctions that lead to unhealthy living conditions, to use social analysis both to explain and to de- the effects of war including consequences for refu- plore human suffering. Its key texts draw our at- gees and internally displaced people,26 and pov- tention not merely to the suffering of the erty—as well as labor and employment conditions wretched of the earth but also to the forces that (including occupational safety) and the distribution 21 promote that suffering. of resources within and among nations.27

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The unequal distribution of global resources, rooted programs have been implemented for medical facul- in colonial history and sustained in the present ty.34 Such training is perhaps overdue in U.S. medi- through modern market mechanisms, drives much cal schools. A Committee of the Red Cross report of the social production of disease.28,29 While we on “enhanced interrogation techniques” used by the cannot require that all physicians be scholars of U.S. Central Intelligence Agency on detainees35,36 world history or global political economy, they notes the participation of health professionals in the should at least be familiar with how large-scale so- process, as reported in The Lancet37 and The New cial forces work locally to make their own patients England Journal of Medicine.38 sick. To advocate for social justice, one must be fa- In envisioning redesign of U.S. family medicine miliar with the mechanisms of injustice, including residencies, Leach and Batalden recommend putting its ideological and historical underpinnings. “systems issues on the table as legitimate elements “Structural violence” refers to societal or institu- of the curriculum.”39 The Institute of Medicine tional factors that preserve inequity, injustice, and (IOM) has taken a similar stance in the context of human misery—the ways that the unequal distribu- racial and ethnic health disparities in the United tion of suffering becomes embodied and experi- States. The entrenchment of health disparities de- enced as violence by the powerless. James Gilligan spite a well-funded modern health care system is defines structural violence as widely recognized as unacceptable. The IOM report Unequal Treatment recommends that the increased rates of death and disability suf- fered by those who occupy the bottom rungs of [o]rganizations responsible for the education, society, as contrasted with the relatively lower training, and licensure of health and medical death rates experienced by those who are above professionals should develop special initiatives them.30 to increase levels of awareness of healthcare

31 disparities among current and future healthcare First introduced by Johan Galtung, the term has providers. 40 helped clarify the structural relations between ine- quality and illness, most clearly in a series of essays This recommendation by the IOM would be ad- and works by Paul Farmer and colleagues that show vanced significantly by including the principles of in concrete examples the ways that severe poverty social justice in medical education. constrains personal agency and contributes to unjust health disparities.32 The global movement for health and social jus- The U.K. Department of Health has concluded tice that “neglecting people’s human rights is bad for Studies of structural violence have led to a deep- their health. In contrast, the protection and promo- er understanding of the social determinants of 41,42 tion of their human rights is not only good for indi- health. Academic interest in global health equity viduals’ health; it makes for better services for eve- is burgeoning. In increasing numbers, medical stu- ryone.”33 dents in the U.S. and other wealthy countries are Responding to global political and economic expressing an interest in global health, inspired by forces, some countries are integrating health and the examples set by organizations such as Partners human rights into medical education. In South Afri- In Health and Médecins Sans Frontières. Trainees ca, the Truth and Reconciliation Commission found who sign up for international electives abroad are that many physicians had been active or passive par- increasingly guided by principles of social justice, ticipants in torture. In response, the Health Profes- asking not “What can I learn from this experience?” sions Council of South Africa has made human or “How can this experience help me improve my rights teaching mandatory for higher education insti- clinical skills?” but rather "How might I best serve tutions: competencies and curricula in health and the destitute sick?” or “How might I improve their 43 human rights have been developed, and training situation?”

Social Medicine (www.socialmedicine.info) - 164 - Volume 7, Number 3, October 2013 Implementing a social justice curriculum in med- Figure 1. Core competencies of the Doris and ical education Howard Hiatt Residency in Global Health Borrowing from the South African model, we Equity and Internal Medicine suggest several competencies as the basis for a so- cial justice curriculum: • Evaluate and address the social determinants of health and disease. Knowledge: • Acquire clinical skills necessary to take care 1. Familiarity with international human rights con- of patients with a wide range of health prob- ventions and professional codes of ethics lems in resource-poor settings. 2. Familiarity with national legislation pertaining • Conduct research relating to health dispari- to health and human rights ties and global health. 3. Awareness of services for refugees, immigrants, • Attain skills in advocacy, leadership, and indigent individuals, and survivors of human operational management of global health rights abuses programs. 4. Understanding the social determinants of health • Obtain in-depth knowledge about the specif- and implications for their own practice commu- ic and medical problems affect- nity. ing one geographic region of the world. • Develop a strong base in the ethics of inter- Attitudes: national medical practice and research. 1. Viewing all people as worthy of dignity and • Master language fluency to practice medi- respect cine, conduct public advocacy and carry out 2. Willingness to assume an advocacy role and research in the geographic area of interest. work for change 3. Approaching patients in a non-judgmental and ters, and homeless shelters; cross-cultural health nondiscriminatory fashion. initiatives; health literacy programs; outreach vans;

Skills: and sustainable global health projects; linkage with 1. Community needs assessment and community population health initiatives; and social medicine development experience reading groups are examples of existing projects 2. Advocacy and lobbying experience that contribute toward satisfying a social justice 3. Ability to work in interdisciplinary teams and competency. However, service learning in the con- diverse settings. text of delivering health care to the underserved must be connected to the need for social justice in Focusing on methods to promote self-reflection health care. By stating that social justice is an inte- and critical thinking should guide curriculum devel- gral value to our health care and medical education opment. Site visits, role playing, reading groups, systems, we set both a standard for learners and a reflective journaling, small group discussions, train- moral compass for . ing on the use of the media, and community projects The Doris and Howard Hiatt Residency in Glob- may all provide opportunities to model and teach the al Health Equity and Internal Medicine44 takes a principles of social justice within a medical school comprehensive approach toward core competencies or residency curriculum. A focus on the institutional (Figure 1). culture and organizational forces within hospitals, In 2010, a student-initiated Dean’s Certificate of academia, government agencies, and payers that Distinction in Social Justice was introduced at the may at times be barriers to the effective delivery of John A. Burns School of Medicine (JABSOM), care should be examined. University of Hawai‘i at Mānoa. The certificate Many medical schools and residency programs provides formal acknowledgment at graduation for have projects that evaluate and address specific those students who demonstrate yearly progress to- health needs in their communities. Education and ward understanding and applying the basic tenets of training in public hospitals, community health cen- social justice in medicine by participating in a range

Social Medicine (www.socialmedicine.info) - 165 - Volume 7, Number 3, October 2013 Figure 2. Social Justice Curriculum, John A. Burns School of Medicine (JABSOM), University of Hawai‘i at Mano

of academic and community activities. Interested dence-based health system change. Adding training students crafted the curriculum for the certificate in social justice would lift the educational focus and shepherded it through the Office of Medical above the hospital and clinic setting and provide a Education and the Dean’s Office, obtaining admin- framework to evaluate the dynamic interaction be- istrative approval with minimal faculty involvement. tween socioeconomic forces and health. Key features of the curriculum are summarized in a diagram developed by JABSOM medical students Acknowledgments Adrian Jacques Ambrose, Teresa Schiff, and Kathe- The authors thank Haun Saussy, PhD, and Jo- rine Rieth (Figure 2).45 seph Rhatigan, MD, for their editorial assistance. A Human Rights and Social Justice (HRSJ) Scholars Program was launched in the 2011–2012 References academic year at the Mount Sinai School of Medi- 1. Wilkinson RG. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996. cine.46 In 2011, Georgetown University School of 47 2. Hixon AL, Maskarinec GG. The Declaration of Al- Medicine began a Health Justice Scholar Track. ma Ata on its 30th anniversary: relevance for family These projects, like the one at JABSOM, link social medicine today. Fam Med. 2008 Sep;40(8):585-8. accountability to health care outcomes by requiring 3. Virchow R. Report on the typhus in Upper participants to engage in community and scholarly Silesia. Social Med. 2006 Feb;1(1):11-27, 28-82, 83- 98 [cited 2013 Oct 11]. Available from: projects that addresses social determinants of health, http://www.socialmedicine.info/index.php/socialmed and demonstrate that medical students, even without icine/issue/view/5/showToc faculty initiatives, recognize that social justice, is, in 4. Rhodes R, Battin MP, Silvers A, editors. Medicine fact, the heart of medicine. Faculty should encour- and social justice: essays on the distribution of health age and support these efforts and help nourish ef- care. New York: Oxford University Press; 2002. 5. Marmot M. Achieving health equity: from root caus- forts at other schools. es to fair outcomes. Lancet. 2007 Sep 29;370(9593):1153-63. Conclusion 6. World Health Organization. Closing the gap in a Just as the health system is being transformed by generation: health equity through action on the social political, social, and economic pressures, medical determinants of health. Final report of the Commis- sion on Social Determinants of Health. Geneva: education must respond by creating physicians ca- World Health Organization; 2008 [cited 2013 Oct pable of systems-level thinking and of directing evi- 11]. Available from

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