Observations Border Crossing

Advocacy for all

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2212 (Published 03 June 2009) Cite this as: BMJ 2009;338:b2212
  1. Tessa Richards, assistant editor, BMJ
  1. trichards{at}bmj.com

    Where health agendas become swayed by narrow factional interests, doctors need to speak out for the common good

    “If things are that bad,” demanded the medical student at the back of the room, “why aren’t you doing more? I’m only 19, and it’s my generation that is going to be left to confront climate change.”

    Just for a moment the room went quiet. The middle aged experts at the Chatham House conference on global health security had spent the whole morning summarising data about the daunting pace of climate change, its increasing impact on health, and the need to mitigate its effects on the world’s most vulnerable people. What more was the student expecting them to do? Chain themselves to railings? Lie down on the runway at Heathrow?

    They did not ask, and she did not elaborate, although it would have been an opportunity to mention that this is an issue where some doctors have gone into activist mode and are leading a global campaign to persuade governments to reduce carbon emissions and help the world’s poorest populations adapt to the effects of global warming (www.climateandhealth.org).

    It’s fair to acknowledge, however, that with notable exceptions doctors are more inclined to advocate for individual patients and their own professional interests than lead or actively participate in international health and human rights campaigns. We may accept the importance of the messages from the World Health Organization’s Commission for Social Determinants of Health and note the rallying cry of Global Health Watch’s alternative world health report. But in the main most of us are happy to get on with our day jobs, leaving it to others to take arms against the inequitable nature of the global health order.

    Part of this may be a function of age. Most medical students have high humanitarian ideals and many campaign for them through the student network Medsin (www.medsin.org) whose members bring passion and energy to international health debates. Yet few go on to join the health professionals’ lobby group Medact (www.medact.org), which is also chiefly concerned with tackling global health crises and inequalities.

    Some believe that it’s not only age that douses students’ zeal, and they put the blame on a system of medical education and postgraduate training that offers too little scope or practical opportunities to get a wider and more global perspective on health. Margaret Reeves, a general practitioner from Banbury, member of Medact, and critic of the educational system, explained her views to me.

    “I think the system is too formalised, sterile, and contained,” she said. “It produces doctors who are ill prepared to think about the wider social, economic, and political determinants of health. And even if they are keen to engage in health advocacy beyond their surgeries, few have the skills to raise debate and influence agenda in, or outside, the health sector.”

    Reeves and colleagues have recently spent a week’s leave running a health activism course in London. The course has been developed by the People’s Health Movement, a network of academics, health professionals, and individuals working for non-governmental organisations who “share a vision” about tackling health inequalities. Such courses have been run for years in developing countries, but this was the first in the United Kingdom. The courses aim to heighten awareness of the factors that underpin health and health inequity nationally and internationally, to teach participants advocacy skills, and to show them how to integrate “intelligent and strategic activism” into their daily work

    Most of the people on the London course, which I observed for a morning, were studying for postgraduate degrees in public or international health. In these disciplines it’s easy to see the value of learning how to link interested people together, involve local communities, influence the research agenda, use the media to disseminate messages, and mount health campaigns.

    But arguably these skills are useful for other doctors too. Most of us have local concerns, not least with respect to Cinderella service provision, where judicious professional advocacy can achieve a lot.

    Skilled professional advocacy is also needed to defend the common good. Everyone is pushing health messages these days, and those with factional interests are most adept at it. The drug industry has legendary skill; but political debate and health agenda are swayed by many other groups, including, of course, individual patients. The media feed on stories where people have been “cruelly denied” promising treatments or fallen foul of other shortcomings of the NHS.

    Such stories have helped fuel an insalutory campaign in the United States against Barack Obama’s plans to reform the country’s costly and inequitable health system (BMJ 2009;338:b2058, doi:10.1136/bmj.b2058). The campaign exposes the tension between the rights of individuals and the rights of the population as a whole, and its protagonists are milking the first of these to the full.

    Ferner (BMJ 2009;338:b2221, doi:10.1136/bmj.b2221) rebuffs the campaign’s attack on the UK National Institute for Health and Clinical Excellence (NICE) and underlines the importance of funding research to determine the cost effectiveness and comparative effectiveness of different treatments. As the economic crisis bites, and concern about the financial sustainability of health systems mounts, it’s clear that all countries need bodies like NICE. Health systems need to provide better value for money—and equitable care.

    This is not a sexy message to sell. Maybe NICE and its sister agencies should recruit some charismatic figureheads to promote their cause and to counter images of the “NICE is nasty” variety. Joanna Lumley springs to mind. But even charismatic leaders need the support of well informed advocates, and more of us should take this role seriously.


    Cite this as: BMJ 2009;338:b2212

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