Social Justice: the Heart of Medical Education

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 health system 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 economically 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 Community Health derives from 19th century social medicine, whose John A. Burns School of Medicine founder Rudolf Virchow 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 Global Health 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 population health 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, health literacy, 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- pharmaceutical industry—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 informed consent, 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 health education 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

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