What has social injustice to do with medicine?
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c842 (Published 11 February 2010) Cite this as: BMJ 2010;340:c842
All rapid responses
Fiona Godlee [1] and others [2] refer to the Marmot’s report [3] and
conclude that GPs and society cannot afford inaction. However, the real
question is not if, but how GPs could tackle inequalities in health. We
know that the health care system itself is not able to establish equity in
health. Moreover it could be shown that lower classes already consume more
GP visits than higher classes (at least in Germany and I expect same
results for the UK). The astonishing point is that these result persists
after adjusting for age, sex, and morbidity. Therefore GPs would not help
to reduce inequality by simply shifting care or resources to unprivileged
groups. On the contrary, the largest share of inequality today could be
explained by educational level, income and lifestyle – and only the latter
could be tackled by GPs. To give advice on lifestyle – especially
concerning smoking habits and exercise – seems to be the action with
highest evidence if GPs would like to help reducing inequalities. However,
this means GPs must partly reinvent themselves as social worker. If this
is a desirable task for all GPs is still unclear.
[1] Godlee F. Editor's Choice: What has social injustice to do with
medicine? BMJ 2010;340:c842.
[2] Hunter DJ, Popay J, Tannahill C, Whitehead M. Editorials: Getting to
grips with health inequalities at last? BMJ 2010;340:c684
[3] Marmot M. Strategic review of health inequalities in England post-
2010. Marmot review final report. University College London.
Competing interests:
None declared
Competing interests: No competing interests
Many words, which arouse subjective understanding, have surfaced in
this very interesting editorial.
"Will Michael Marmot’s crucial review of health inequalities in England "
– I ask, when has there ever been a time in this great land, or any other
place on this planet, since the beginning of time where has not been
health inequality for any of the multitude of reasons- finance, access to
service, quality/quantity of health services and personnel etc? The same
goes for in other spheres of life - education, career, quality of life,
taxation etc.
Even in a system to overcome such an irrevocable fact.
Thus it is frankly no surprise that neither Marmot’s or Black's
report would differ. The same parameters and their values exist back in
1980 as they do in 2010 and will do so in 2040 onwards.
No report will shed anything new. for what these reports and others
to come, will show a fact of nature, a fact of life, a fact of human
society. Thus to say "Over time, greater understanding of the complexities
of how things work at the national and global level has added
sophistication to his message while removing nothing of its power", I
disagree - such statement shows only now people are becoming aware that
always was so before.
"Are we—doctors and politicians—as powerless to act as she suggests?"
- this is an automatic suggestion that we as doctors have the onus ontop
of being medical clinicians, to also be "priests" and clinical
sociologists, to be like prophets to resolve this situation of social
injustice!
So with Dr Hedge I agree that "Civil engineers, politicians, social
workers, philanthropies, and the altruistic social organizations should be
able to do something in keeping the health of the public.", and thus
minimize the social injustice to health care.
Yet the WHO report does point to an ethical and moral issue "why
treat people...without changing what makes them sick?" - for this involves
not only doctors, but an array of others involved for this to work - and a
break in any part of the line (be it due to complacency, corruption,
ineptness, low morale, low quantity/quality staff, bad communication, high
level bureaucracy) can cause no alleviation to the social injustice to a
minimal. Thus I concur with Marmot that action has to take place across
ALL sectors homogenously and in synch, all singing the same hymn in
solidarity.
Thus wise advice that is not being done already should be by Marmot:
1. providing universal access to good quality care.
2. collaborating with other sectors such as transport and social services.
3. understanding and measuring outcomes.
Thus I disagree it is not that countries are failing to answer for
all know the answer; but to implement it is harder than it is with. In the
NHS, we have too many "cooks spoil the broth" i.e managers, and managers
for managers, and managers for this and that, and government targets and
performance level, that we are missing the whole point of what is the
health system and to maximize the true potential that we have to help
those indeed - the medical clients (patients as one may still like to call
them). In addition the average doctors have hardly any say in how to get
things more efficient on a ward level, so let alone on a social system, is
rather too much to ask!
My peers from Africa and South Asia, tell of growing corruption and
complacency to help, and hinders any level to help, which if overcome at
the front line, is envisages at a higher level to get things done. It is a
lose lose situation it seems as it has always been so.
Some may sasy the closes was in communist Russia, where health care
system was free and all be it poor or rich (mainly the politicians) were
entitled to full level of care and treatment - no postcode lottery (as in
NHS), or ones insurance (as in USA), and many doctors from the Baltic’s
and East Europe have told me how system was much better for all and money
and technology was on object to treat the patient. A great contract where
today in their home countries many even regret becoming capitalist or part
of "new empire"/European Union with a great disparity of health care and
the social health systems are all but in name, with huge numbers of doctors and
nurses laid off and wards closed, and hospitals are as in dark medieval
times acting more as infirmaries to care only before one passes away.
The NHS is socialist whale swimming in a cesspit of capitalism, in a
right-wing "EU" neighbourood, as part of a defragmented city of different
cultures, ideologies, prejudices and bias, let alone priorities of each
household ("country").
Let us pray that whichever Political Party wins the upcoming
English/"British" General Elections of 2010, will revive the NHS from its
embittered coma status, and bring it back to life with regain of status
and respect duly deserved to the doctors and allied health professionals,
that our cousins across the waters - East and West - and our past wise
doctors in NHS had, more than we do in NHS this new century in parallel
to avoid the great disparity of health care not just across the engrained
British class system but across geographical locations that I have noticed
varies substantially across each deanery in England and Wales.
Peace to you all!!
Competing interests:
A British Pro-NHS, NHS working doctor of old school thought of medicine as an art and a way of life not as a career.
Competing interests: No competing interests
Dear Fiona Godlee,
Social injustice has everything to do with illnesses.
Poverty is the mother of all diseases from common cold to
cancer. A child born to a poor mother will have a very small
hippocampus major, small pancreas, small vessels etc making
that child get all killer diseases in the 30s; in addition,
the small hippocampus unfits the mind for any intellectual
pursuits.
It is not prevention that should be our motto but health
promotion. Disease is failed health promotion. Prevention
brings in screening in its wake which promotes disease
mongering. Every human body is built to last as long as it
can, thanks to the immune system. No one should try to be
here for ever, as s/he will certainly not succeed, doctors
and medicines notwithstanding. The immune system needs
boosting on a regular basis to keep the person disease free.
Modern medicine is not doing that. Clean water, air and food
are of vital importance. One third of the world population
lives on less than one meal a day. Nutritional immune
deficiency syndrome (NIDS) is the biggest killer of children
in poorer countries, deadlier than AIDS.
Poverty economics has to be learnt not in Oxbridge but in
the slums of the poor countries. Then only one gets the true
picture. It is akin to doing Dictator experiments of John
List in real life situations which showed that mankind is
not altruistic, unlike the controlled experiments of the
2002 Nobel winning work of Vernon Smith and Daniel Kahneman,
showing humankind to be hard wires to be altruistic.
The medical profession, like all other professions, has
become homo economicus. We, doctors, are not concerned with
poverty eradication lest we should break our own rice bowl!
Doctors can never survive without patients while patients
could survive without doctors!
Hospitals and doctors have very little to do with health of
the populace. More doctors and less health has been the
finding of the 14 industrialised countries’ study. (JAMA
2000; 284: 483-485) Civil engineers, politicians, social
workers, philanthropes, and the altruistic social
organizations should be able to do something in keeping the
health of the public.
Food, shelter and water with a clean
environment, coupled with economic empowerment and ethical
education should do the trick to keep our immune system at
its peak. Will the powers that be wake up to this reality
please?
Yours ever,
bmhegde
Competing interests:
None declared
Competing interests: No competing interests
With “Social injustice” in the title I was hoping for intelligent
thinking which went well beyond the mistaken pursuit in Hunter’s paper of
‘equality’.
Hunter et al. listed six policy recommendations to reduce health
inequalities, repeatedly pleading for efforts to be differentially
focussed to ‘reduce the social gradient’.
- Give every child the best start in life: increase the proportion of
overall expenditure allocated to the early years and ensure it is focused
progressively across the gradient
- Enable all children, young people, and adults to maximise their
capabilities and have control over their lives: reduce the social gradient
in skills and qualifications
- Create fair employment and good work for all: improve quality of
jobs across the social gradient
- Ensure a healthy standard of living for all: reduce the social
gradient through progressive taxation and other fiscal policies
- Create and develop healthy and sustainable places and communities
- Strengthen the role and effect of the prevention of ill health:
prioritise investment across government to reduce the social gradient
Each objective is at odds with the others. For example, if we strive
for every person to maximise their capabilities, will that not inevitably
result in very wide differences between them ? What value is a social
equality which holds people back to the level of the worst, or even ‘the
average’ ? Moral resolution of the intrinsic confusion and conflict
between those objectives is the stuff of every political credo.
The very term ‘social inequality’ is of questionable ethical
validity. My preferred terms are social fairness and justice.
Aristotelean equity focuses more appropriately upon justifying why
different people should be treated differently, whilst requiring that
identical cases be treated equally. This goes to the heart of the matter.
What factors should count ? What makes a case special ? What value if we
all end up equally unsatisfied ? From Cuba , through New Zealand, to
Sweden, the great benefits of a socially-cohesive and communitarian
approaches to health improvement, are not so much that they reduce
inequality ( in most cases they exacerbate the gap), but rather that they
have improved the overall position ! With an incoming tide not all boats
float, and of those that float some will rise more than others. Our task
is to keep each and every patient afloat, however unequally !
Can we get on with effective health improvement for all, without this
envy of another’s good fortune ? Medicine matters only if we are the
better for it. What counts is what works.
References
Tony Blakely, Martin Tobias, and June Atkinson
Inequalities in mortality during and after restructuring of the New
Zealand economy: repeated cohort studies
BMJ Feb 2008; 336: 371 - 375; doi:10.1136/bmj.39455.596181.25
David J Hunter, Jennie Popay, Carol Tannahill, and Margaret Whitehead
Getting to grips with health inequalities at last?
BMJ Feb 2010 340: c68
Competing interests:
None declared
Competing interests: No competing interests
To the Editor:
You have hit the "nail on the head" by exposing the social
injustice in medicine.(Editor : BMJ 2010; 340, c842.
February 11)
This is the dilemma facing the U.S. Healthcare in its
present form and practice.
There appears to be a misconception by the average American
who holds freedom of choice dearly and the idea of
socialized medicine as a cure administered and controlled by
big government. In reality, socialized medicine may be
looked upon not that of big government control, but rather
socialization of various healthcare organization and to
streamline the way healthcare is administered to patients,
making the process equitable for all patients. The
introduction of the practice of preventive medicine as an
effective cost cutting measure is relatively new and should
be at the forefront of care.
Historically, medicine has evolved from its early days of
treating infectious diseases to the next plateau of
diagnosis and treatment of metabolic, immunologic,
cardiovascular, neurologic, pulmonary and cancer diseases.
And now to the preventive phase which in a way defeats the
historical traditional medical practice.
However, sadly what has spoiled the practice of medicine and
changed the one on one doctor patient relationship, is what
I call the business of medicine. the latter has skyrocketed
the cost of healthcare causing social injustice.
The solution is to remove the business of profit making in
healthcare and to halt the idea that a patient's illness is
a commodity to profit from.
Competing interests:
None declared
Competing interests: No competing interests
Social inequality is prevalent in the world. This applies to medicine
and provision of healthcare facilities as well.
The NHS is a leading example of an effort to provide equality of
healthcare to all individuals. But this effort at egalitarianism is not
complete. A two tier healthcare system exists in many countries including
the UK, where,
publicly funded healthcare coexists with private practice and medical
insurance. As such, people belonging to a
higher social strata have access to better healthcare facilities with
opportunities to access healthcare in other countries as well.
The Strategic Review of Health Inequalities in England chaired by Sir
Michael Marmot sets out evidence based
proposals to reduce health inequalities from 2010. The Review followed the
publication of the global Commission on Social Determinants of Health,
also chaired by Sir Michael Marmot and published by the World Health
Organisation. The Commission on Social Determinants of Health proposed
that countries should implement strategies, based on their particular
problems, which lead to improving health equality.
Amartya Sen in his book The Idea of Justice brings out the importance
of public reasoning in the progress towards
social equality. According to him, the hunt for spotless justice is a
fantasy because societies full of actual human beings will never agree on
a final, perfect set of institutions and rules.
Most people will agree that the concept of attaining total social
equality is a myth. Disparities in provision of healthcare facilities will
remain but the gap can certainly be narrowed.
Competing interests:
None declared
Competing interests: No competing interests
Power to the powerless
It was a real pleasure to read the responses above and find kindred
souls. Munir Nassar’s comments about the average American and their desire
for ‘freedom of choice’ illustrates Dr Hegde’s remarks that mankind is not
altruistic.
Ultimately, medicine cannot rely on individual doctors to reduce
social inequality anymore than a government can rely on its voters.
Doctors – like others – are not naturally altruistic. They may think they
are, or they might start out that way, but for most, that is not their
primary drive. Ultimately, for most, it is a worthy profession at an
individual level, and one that benefits other individuals – i.e., the
patient across the consulting desk. There is nothing wrong with this per
se, and indeed, it is more natural to the animal instinct of self-survival
– Richard Dawkins would call this our selfish gene.
For medicine to exact social equity, the system has to encourage it.
Why is work abroad in low-middle income countries not hard-wired into the
medical career ladders of physicians in developed countries – and
increasingly more difficult to do in the current economic climate? Why do
more doctors aspire to work in leafy suburban or rural general practice
than in surgeries in deprived inner-city areas?
Your editorial presents one solution – i.e., raising awareness. I
believe many doctors can become more altruistic – certainly, I think I
have encouraged my junior doctors on my night shifts this week with my
meandering polemics on my career and ideals. However –as in the failure of
individualised health promotion – social inequity will only be righted if
the system endorses it. The best way to prevent disease is not health
promotion, but health protection - health behaviours are not “lifestyle”
variables, governed largely by individual choice and therefore a matter of
individual responsibility, but are socially patterned and reinforced in
groups. [1] The epidemic of infectious diseases was not eliminated in the
developed world by encouraging everyone to hand wash with soap, but by
policies such as sanitation and provision of clean water to all. With the
current financial crisis driven by the greed of a few and a lack of
regulation of the system, the harm caused by a system that does not stem
destructive (for society) individual self-interest is clear to see.
The answer to social justice may ultimately lie in less choice for
the individual in exchange for benefit to the wider community. Such
socialism however is mostly unrealistic, suppresses the natural drive of
humans and can be ultimately detrimental to the society it seeks to serve.
To both lessen the angle of the see-saw of social inequality whilst also
lifting the whole see-saw up, we should engineer society such that the
more desirable choices an individual citizen or doctor could make in their
life or career should ultimately lead to a more equitable society for all.
To achieve that requires much more than simply recruiting doctors to the
cause, but needs those in power who control their careers to act – as they
can either encourage or suppress our inherent selfishness as humans. Until
then, we - as doctors -will indeed remain powerless in social injustice.
Reference
1. B. Bloom. The future of public health.
http://www.hsph.harvard.edu/review/review_2000/specialfoph.html
Competing interests:
Someone who works in Professor Marmot's department, has the same outlook as him, but feels powerless still
Competing interests: No competing interests