Saturday, November 17, 2012

Why doctors need to be politically engaged

This is a guest post by David Werner, Healthwrights. david@healthwrights.org

A few years ago, in the public market of the city of Mazatlan, Mexico, a thin, tired-looking woman with a sick baby in her arms approached me, asking for money to buy medicine. A doctor she had just consulted had told her that her baby had signs of pneumonia. And indeed the baby was breathing in short rapid breaths with flaring of the nostrils. She handed me a doctor's prescription for one of the newest, most expensive broad-spectrum antibiotics on the market.

"I spent nearly everything I had to pay the doctor," she said, "and can't begin to pay for this medicine."

"Were any lab tests done to find out what microbe is causing the infection?" I asked.

"No." She shook her head. "He just examined the baby and wrote this note."

I explained to the mother that the expensive new medicine the doctor had prescribed should be used only as a last option, and only after lab-work showed resistance to more standard antibiotics, which are usually safer, cheaper, and less likely to cause dangerous side effects. At a pharmacy, I helped her buy several adult-dose tablets of generic amoxicillin, which she could cut into pieces and mix with breast milk, to give her baby the recommended dosage.

This way, the baby was successfully treated at a cost for medication of about 1/20 of that which the doctor had prescribed. Many doctors, in deciding what to prescribe, give little thought to the fact that the prescription of an expensive new medicine, strongly promoted by the pharmaceutical companies, may in effect be a death sentence to the child whose family is too poor to buy it.

This experience hammered home once again a truth that has given direction to my work over the years: Health is determined more by social, economic, and political factors than by medical and preventive services. The corollary is obvious: Doctors -- if they are interested in promoting health rather than just treating illness -- need to be politically engaged.

This is not a new idea. Rudolph Virchow, sometimes referred to as "the father of modern pathology," said, back in the middle of the 19th century, “Medicine is a social science and politics is nothing but medicine writ large. If medicine is to fulfil her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?”

Health literacy, in the broadest sense of the term, must include being informed and actively concerned about the social determinants of health. Most doctors are well trained in the biomedical aspects of disease but are "health-illiterate" when it comes to understanding how the larger social and political context impacts the health of their patients. This is especially the case when it is a matter of being aware of the underlying obstacles to health that weigh upon the less privileged half of humanity.

Most doctors come from relatively well-off families who have a very limited comprehension of the needs and struggles of the poor majority. It is not enough to pore through publications on the topic -- though that may be a good start. But it fails to provide any first-hand experience. If we are interested in training health professionals who are health literate, medical education should include an extended period of total immersion in a poor community, where doctors-in-training live closely with impoverished people and get to know first-hand the overwhelming complexity of the health-related difficulties they face.

A daring experiment. During the 1970s and '80s, a daring experiment of this kind of "immersion" took place in Mexico (where I have worked for decades in Community Based Healthcare and Rehabilitation). Called "Plan of 36," this experiment transplanted a group of 36 beginning medical students, for their entire first year, into Netzahualcoyotl, a huge slum community on the fringe of Mexico City. When this service-oriented initiative began, unemployment in "Netza" was over 60%. There was no running water or sewage system, and only one health centre for over a million people. On the first two days of "med school" in the slum, each student visited 30 destitute families (15 each day), asking them about their most urgent health-related needs and the difficulties they encountered in meeting them. Based on what people told them, the students with their professors planned their first year med-school curriculum. Training was designed to enable the students to help the slum dwellers they'd befriended cope with their health-related problems as best they could. Because most families were large, during that first year of medical school the 36 students provided basic health services, information and advocacy to more than 10,000 underserved people!

Although, for their remaining years of medical school, these students returned to a conventional hospital-based curriculum, what they learned during their first year's "total immersion" apparently stuck with them. Surveys years later indicate that the "health literacy" they'd gained had significantly increased their socio-political commitment to, and empathy for, the underdog. An unusually high percentage of these students, upon becoming doctors, ended up working in community health programmes and/or became activists promoting the health rights, environmental improvements, collective organisational capacity of los de abajo (“those on the bottom”).

By contrast, most doctors coming out of the conventional medical curriculum -- which is more concerned with sickness than with health -- joined, without question, the medical system that is profit-driven rather than health-driven. They saw little reason to try to change it. In this way they ended up becoming part of the problem. A prevailing profit-driven system leads to the suffering and/or death of millions of people every year -- mostly of impoverished people who have little voice in the decisions that affect their lives.
An example from the Philippines will provide us with a deeper understanding of what "health literacy" means, at community level. Several years ago I joined a group of health promoters from Latin America on an exchange visit to the Network of Community Based Health Programs in the Philippines. In a poor village on the outskirts of Tacloban we watched health workers in the Makapawa Health Program weighing babies to monitor their growth. Proudly they told us that in the two years since the program began, the death rate of young children -- which had been very high -- had dropped significantly. We asked why. The health workers thought it was because of the "health talks" they gave mothers about nutritious foods to give their children.

But the mothers there disagreed. "That's not so!" they insisted. "Nurses and health officers have come to our village for years, lecturing us about what foods we should give our children. We know all that! If we don't feed our kids properly, it's not because we don't know what foods they need. It's because we don't have the money to buy the foods -- or to feed our children enough!"

The mothers, however, agreed that their children were healthier and that fewer were dying since the health programme began. So we asked the mothers why. No one had a good answer. We asked whether their wages had increased or food prices had dropped -- but they said the opposite was true.

Next, the local health workers took us to see a project to reintroduce the use of traditional herbal medicines in the treatment of common ailments. In groups of 15 families, people would come together to prepare simple home remedies for coughs and colds, skin conditions, indigestion, aches and pains, and minor injuries. For diarrhoea -- the most common child illness -- they made what was essentially an oral rehydration drink, with correct amounts of sugar and salt, together with guava juice and crushed banana to add potassium and other needed minerals.

After the group demonstration, we talked with the mothers about the possible impact of their herbal remedies on health.

One mother said, "We use our homemade cures a lot for our children's ailments, and most of them get well."

"That way," said another mother, "we don't have to take the long trip to the city to see a doctor, and buy expensive medicine in the pharmacy."

Other mothers pointed out that, thanks to the homemade cures, they saved a lot of money on travel costs, doctor fees and medicines. With the money saved they were able to buy more food.

"Good lord! Do you realise what we're saying?" exclaimed a mother. "We're saying it was medical care that was killing our children! What we spent on the docs and drugs meant we had less for feeding our children!"

With a gleam of discovery on her weathered face, a grandmother with a little girl nestled beside her said, "So at last we know why our children are healthier! Now we've taken at least part of our health into our own hands, and we have more money for food."

And so it was that these village mothers -- though many couldn't read or write -- became more "health literate." They had begun to analyse and act upon the root causes of their poor health.

The experience of these village mothers in the Philippines is by no means exceptional. In many majority world countries -- and even in the United States -- one of the most common causes driving low-income families into absolute destitution is the high cost of medical treatment, especially for major illnesses or emergencies.

In the face of such examples, we must ask ourselves two key questions:

-- To what extent is medical care, as commonly provided today, an obstacle to health?    
-- How can ordinary people read the situation more clearly and take collective action?

Doctors and other health professionals who are truly concerned about the health of the people in their communities will necessarily find themselves proactively engaged with a number of different "political" issues that have an obvious impact on health:

Equity. Something is clearly unhealthy in a world where the gulf between rich and poor continues to grow, and where nearly half of the global population of 7 billion suffers from health-compromising nutritional problems. (Today over one billion people are chronically hungry while over two billion are insalubriously obese.)

Allocation of resources. In today's globalised economy, Death apparently has greater value than Life. The world's governments spend far more on the instruments of war and arms than on healthcare and education combined!

Access to medicines and services. Effective medicines and services are useless if geographical and economic factors put them beyond the reach of people who need them.

The need for universal health care. Doctors who are health literate, and want to become politically engaged, would to do well to join the growing popular demand for universal health coverage, so that families will no longer be at risk of having the cost of illness ruin their lives.

The central importance for health of such basic things as adequate calories, clean water, good sanitation and unpolluted air. The World Water Council reports that more than one out of six people lack access to safe drinking water. That's 1.1 billion people. More than one out of three (2.6 billion) people lack adequate sanitation.

The role of traditional health workers. To protect powerful economic monopolies, many countries have outlawed the "unqualified" practice of traditional healers, lay midwives, and others who provide care within the economic, cultural, or geographic reach of the poor.

Perhaps the matter can be best summed up by reflecting on the meaning of the term "politics." At its core, politics has to do with the distribution of power. For the most part, our present health system is run for the economic growth of powerful and lucrative monopolies (such as for-profit corporate hospitals chains, pharma companies, health insurance companies and medical device manufacturers) that place urgently needed, potentially life-saving attention out of the reach of millions.

Today 8 million children still die annually from easily preventable and treatable conditions because the world's ruling class does not give priority to the global goal of Health for All. For health professionals to become "politically engaged," means to actively advocate for a fairer, more compassionate, egalitarian society: one where everyone has a representative voice, and where healthcare, adequate nutrition, decent living conditions, and empowering education are basic human rights. As Dr Rudolf Virchow said over a century ago, “Medicine is a social science, and politics is nothing else but medicine on a large scale. Physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” If more of today's doctors would aspire to this political vision of Virchow, the practice of medicine would contribute a lot more then it now does to the goal of 'Health for All.'


HELP is organizing a conference on “ Putting Patients First Through Health Literacy  “. This will be on Sunday, 2nd December’12 at Nehru Center at 10.30a.m. to 1.p.m.  The website is www.patientpower.in/2012

The conference will be followed by a health literacy workshop in the afternoon. Helen Osborne, President, Health Literacy, a world renowned  Consultant from US , will be delivering the keynote and conducting the workshop.  Her website is at www.healthliteracy.com

At this time, we will be releasing the book, Deciphering Medical Gobbledygook: Promoting Health Literacy to Put Patients First , authored by Dr Aniruddha Malpani and Juliette Siegfried. This is Chapter 20 from that book

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