On activism

Should Clinicians Be Activists?

Kristen N. Pallok, MD and David A. Ansell, MD, MPH

https://journalofethics.ama-assn.org/article/should-clinicians-be-activists/2022-04

This articles uses a case and commentary based approach to this question. The case illustrated is that of an undocument uninsured child requiring transplantation for end-stage renal failure.

The article makes several interesting suggestions

It describes competencies for 'social medicine'
It suggests that there is a moral obligation for doctors to practice 'social medicine'
These competencies can be developed into a curriculum for medical education, support commissioning and improve healthcare delivery.

The competencies for social medicine

Structural competencies

Structural competency teaches physicians how social, political, and economic determinants of health cause illness

recognizing how structures like forms of marginalization shape clinical encounters
developing a language of these structures (reducing epistemic injustice)
rearticulating ‘cultural’ formulations in structural terms
envisioning structural interventions
developing structural humility (the awareness that professionals must be led by the community to solve problems)

Allyship

Allyship is an intentional practice in which persons in positions of privilege and power build authentic relationships with marginalized groups in order to address unjust power structures.

https://en.wikipedia.org/wiki/Allyship

Accompaniment

'an ethical value expressed in actions of pragmatic solidarity with the community'

It is a deeper form of involvement in which the doctor is present with the individual or community towards health equity.

Activism

'Activism requires health professionals to publicly leverage their privilege for social change. In this case, activism meant showing up at demonstrations at the transplant centers, convening meetings with the demonstrators and transplant leaders, and being vocal supporters for the petitioners in the media and in dialogue with political leaders'

Uses

Health equity
Deep End issues
Climate change & sustainable health
Adverse childhood events & trauma informed care

Suggested steps for social medicine

Practice structural competency by speaking out about health injustice.
Engage with the community: 'nothing about us without us'
Use narrative: Narrative + Data + Action = Change
Leverage public policy to create social change

Related ideas

Social determinants of health

https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

The social determinants of health (SDH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.

The SDH have an important influence on health inequities - the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health

Health inequalities

https://www.cdc.gov/chronicdisease/healthequity/index.htm

Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.

Commercial Determinants of Health

'Commercial determinants of health (CDoH) are the private sector activities impacting public health, either positively or negatively, and the enabling political economic systems and norms'

https://www.who.int/health-topics/commercial-determinants-of-health#tab=tab_1

Helen Salisbury: The commercial determinants of health

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1704 (Published 12 July 2022)

Medical activismMedicine and politics are inseparable. This applies from the very beginning of medical training and throughout doctors’ careers. In most countries, the young people selected to go to medical school are predominantly drawn from a social elite. (The state-educated 94per cent of the school population in the United Kingdom, for example, were given fewer than half the offers for medical training in Oxford).1 They will generally share the experiences, assumptions and values of the privileged backgrounds from which most of them come. As they go through training, medical students almost everywhere will receive an intense grounding in the scientific and technological aspects of medicine but vastly less in the social and political determinants of health. They may be exposed to some of this information (such as the difference in life expectancy between the least and most deprived deciles in England of 9.5 years for males and 7.7 years for females.)2 However, the teachers who impart these facts are equally unlikely to have come from deprived backgrounds themselves, or to imbue them with the sense of outrage that such figures should evoke. Once qualified, most doctors will begin to understand that some of the frustrations they encounter at work arise from political decisions rather than ones made by clinicians and service managers. …

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