The academic discipline of social medicine has always had a political and policy advocacy component, in addition to its core functions of epidemiological, sociological, and demographic research and teaching. For example, in 1790 Johann Peter Frank,1 the German dean of an Italian medical school, delivered a commencement address to newly credentialed young physicians, entitled “The People’s Misery: Mother of Diseases,” in which he argued the economic, environmental, social, and occupational conditions of the peasantry should be changed—and that effort should be part of a physician’s work. Half a century later, Rudolph Virchow famously concluded that “politics is nothing else but medicine on a large scale,”2 in recognition that most social determinants of health are politically determined. A few years later, John Simon,3 the first health officer of London, described the urban working class as “living in some lightless feverbin, breathing from the cesspools and the sewer” and able to afford only stale bread and diluted milk for their children. Simon’s first official report called for Parliament to act to change such conditions and provide financial and other support.
In our own time, we have seen intense epidemiological and sociological research on the social determinants of health (though much less attention to their political origins).4 The special collection of articles focused on “structural competency” in this issue of Academic Medicine5–8 is part of that historical continuum. At first glance, these articles may seem narrowly pedagogic, focused on such issues as how best to teach undergraduate medical students about the social determinants of health. But I believe they raise larger questions.
Five decades as a medical educator have convinced me that most students enter medical school with high idealism. They care about inequity, domestic and global population health status, poverty and its health consequences, lack of access to good health care, environmental hazards, and racial and ethnic disparities in health.9,10 I believe that for a significant number of these students there is a steady erosion of this idealism by the time of residency training, to be replaced by cynicism, loss of empathy for patients, decreasing satisfaction in clinical work, exhaustion, and depression.11 We have no data on the long-term effects of attempted preemptive educational interventions among medical students: Will they stem the erosion of idealism or manifest themselves in social and political activism? We do not know, and meaningful longitudinal data will be difficult to acquire. And so the efforts described in this collection are hopeful ventures into the unknown.
My experience with social medicine training at the City University of New York School of Medicine at City College in Harlem and its predecessor, the Sophie Davis School of Biomedical Education, may be relevant. Our faculty realized that a lecture course on social determinants of health created resistance in students who regarded it as “preaching,” “too political,” and “a time-wasting distraction” from their primary tasks of learning the basic medical sciences and acquiring some early clinical skills. We therefore developed a course almost devoid of lectures in 2000. Instead, second-year students assessed their ZIP codes of residence, recording housing stocks, transportation, retail enterprises including food stores, health care facilities and their personnel, schools and other educational resources, parks and other recreational facilities, and environmental hazards. They then turned to U.S. Census data, past and present, to explore population changes over time in income, race/ethnicity, age, dependency ratios, and occupation. Finally, they mined population and public health data to examine infant mortality and life expectancy, major infectious and chronic diseases, health insurance status and health care utilization, preventable hospitalizations, and the like. In short, they produced a complete community health assessment. The students then repeated this exercise for a different ZIP code characterized by high concentrations of poverty. They were never lectured about the social determinants of health or their relationship with population health status—they discovered it for themselves. As a final task, they formulated specific proposals for medical, social, and political interventions. This was an early exercise in merging their developing clinical identities with their impulses toward idealism and activism.
I observed another kind of merger—combining public health and clinical medicine in one program of health care delivery—by the Delta Health Center (DHC) in rural Bolivar County, Mississippi. The DHC served an African American population plunged into deep poverty, high unemployment, malnutrition, deteriorating and inadequate housing, contaminated water supplies, primitive sanitation, and other environmental hazards by the collapse of the sharecropper system following the rapid mechanization of cotton agriculture in the late 1950s and early 1960s. No local, state, or federal public health agencies were interested in intervening. In 1967 the DHC, therefore, created its own public health department integrated with its clinical facilities: Its Environmental Management Department dug protected wells, constructed safe outdoor privies, repaired crumbling plantation shacks, and organized a 500-acre cooperative farm, drawing on the target population’s agricultural skills and producing thousands of tons of vegetables—not cotton—to combat malnutrition. This entire venture was built on a solid foundation of community organization into 10 local health associations and an overarching health and civic improvement council. The local health associations were independent community organizations setting their own priorities for action; the health and civic improvement council, also independent, maintained an office at the DHC to coordinate most effectively with the DHC’s programs. This, in turn, contributed to ongoing efforts at voter registration and access to some political power by the county’s African American community.
Regarding “structural competency,” we need to ask if teaching social determinants of health and their political determinants is an epidemiological exercise, or if it is a call for political action. If the latter, what is the appropriate role for doctors and other health personnel in taking such action—what are the where, why, and how of it? Do clinicians have responsibility not only for individual patients but also for the health status of the communities from which those patients come, as Donald Berwick12 and others have eloquently contended? Can and should medicine be an instrument of social and political change?
In pursuing answers to such questions, I suggest we should be careful about our understanding of the concept of “structural competency.” If that term refers to a deeper understanding of the real-life circumstances of patients in poverty, that is all to the good. Physicians in their clinical practices need a far more detailed appreciation of the multiple dimensions of poverty—not merely low income and high unemployment, but also limited education in inferior and often segregated schools, lack of health insurance and access to care, the stresses of life in socially unstable and environmentally hazardous communities, dilapidated housing, and high household unemployment. Good screening tools for such issues now abound, and there is evidence that the addition of social workers and civil legal services lawyers to interdisciplinary health care teams improves the sensitization of clinicians to such factors in the lives of their patients.
If, however, “structural competency” is taken to imply that physicians and other health personnel can change politically determined social determinants of health in the course of a clinical encounter, I disagree. Most clinicians have little or no training in advocacy skills. They neither have the time nor are reimbursed for advocacy efforts, most of which will have to occur outside the clinical encounter. Efforts to assist individual patients and more effectively manage their interactions with the health care system, as in the case studies described in this special collection, are worthy and useful, but they are not structural and they do not confront root causes.
Yet it should be noted that structural change is possible, and that in-clinic programs can support structural change outside the clinic. Although not mentioned in the article by Paul et al8 on medical–legal partnerships (MLPs), MLP attorneys collaborated with physicians to take political action in Allentown, Pennsylvania, where 23% of tested children were found to have dangerously elevated blood lead levels,13 far in excess of the 7% rate found in Flint, Michigan. Here, the problem was not lead-contaminated water but the widespread existence of crumbling lead paint on the interior walls of Allentown’s older housing stock. Together, public health physicians and the MLP lawyer affiliated with Allentown’s Federally Qualified Health Center reviewed city housing laws and regulations with regard to lead paint. The standards were low, there were no regular inspections, and there were no meaningful penalties or other incentives for landlords to remove the paint. They drafted a new, much tougher law; brought it (and their data) to the city council, the mayor, and the public; and a new housing code was approved. New population surveys are now under way to verify anecdotal impressions that elevated blood lead levels have been dropping significantly. That is a structural intervention.
A pathway for clinicians to work for structural change already exists and requires dramatic expansion. It involves clinician participation in the work of voluntary nongovernmental organizations (NGOs) and multiprofessional collaborations. It requires the participation of and collaborations with local, state, and federal agencies that deal with housing, transportation, education, urban planning and development, environmental regulation, and health care. It also requires sustained efforts at public education and, ultimately, the active participation of legislative bodies and other political entities.
Existing examples are almost too numerous to count. Physicians for Social Responsibility (PSR), formed in 1961 by a handful of clinicians and associated scientists, mounted both public education and legislative campaigns to document the real medical, social, and global environmental consequences of the use of thermonuclear weapons.14,15 Those efforts continue, with chapters still in existence across the United States. Physicians for Human Rights (PHR),16 launched in 1986 by six clinicians and a lawyer sitting in the backyard of a suburban Boston house, set out to bring the skills of physicians and medical scientists to the documentation of human rights violations, crimes against humanity, violations of medical neutrality, torture, genocide, and other violations of international treaties on human rights and humanitarian crises. It now has global impact, with student chapters in medical schools and universities across this and other nations, and it is still mounting missions and issuing reports on current areas of conflict. (For their efforts, both PSR and PHR have shared in separate awards of the Nobel Peace Prize.)
Perhaps the most striking example is the creation by 20 clinicians in 1964 of the Medical Committee for Human Rights (MCHR) to serve as the medical arm of the Civil Rights Movement during that year’s Freedom Summer voter registration effort in Mississippi.17 MCHR brought hundreds of volunteer physicians, nurses, dentists, psychologists, social workers, and medical students into the state. Subsequently, MCHR formed chapters, involving clinicians and medical students, to work on civil rights and discrimination issues in their own institutions and communities.
It is important to note that all of these organizations mount programs to teach advocacy skills, legislative lobbying skills, and public education and media techniques to their professional and student members. These are useful operational tools.
It seems likely to me that all such efforts will continue but will involve the relatively small percentage of clinicians, medical educators, and others who are willing to commit their time and energy. They will embody the anthropologist Margaret Mead’s observation that no one should ever underestimate the ability of small groups of determined and committed people to change the world.18 In my view, over the next half century they will need, most of all, to unpack the ghettos, the toxic urban concentrations of extreme poverty that have such dire health consequences. Ending residential segregation and affecting other communities’ racial/ethnic composition and income levels will in turn facilitate the integration of public schools and the broader availability of good opportunities for employment.19 Access to college, to medical education, and to other forms of professional training are already a part of the activist agenda and will continue to grow in importance, as will campaigns for universal health insurance coverage and for a legitimate governmental stake in care access, affordability, quality, and continuity. The time period I suggest is testimony both to the difficulty and the importance of these challenges. Collectively, all these efforts—within and outside the spheres of medicine—represent the real operative form of structural competency.
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