Providing medical care for a child who is injured in an auto accident treats the child; advocating for laws that require effective car seats prevents children from being injured in the majority of car accidents. It’s safe to say that providing medical care to patients is a service to individuals, but it is public advocacy that impacts the larger determinants of health. Is advocacy, therefore, a role that physicians are professionally obligated to undertake?
Some of the answer comes from the question, what causes disease? Provision of medical care alone does not address all the causes of poor health; hence physicians, whose task is to promote health, must go beyond medical treatment for individuals, advocating for improvement in the broader conditions that affect health.
There are many determinants of and contributors to health and illness. In addition to the individual behaviors and health practices, determinants of personal health include genetics, demographic factors, exposure to infectious and other illness-causing agents, income, and education. Some people have more control over these factors than do others. Determinants that affect large groups of people include factors such as access to health care, adequate employment and working conditions, clean air and water, safe housing, and freedom from violence. According to the World Health Organization, “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels” .
Social determinants of health are capable of causing far more deaths and disease than the average person might believe. For example, in the United States prior to the Affordable Care Act, 13 percent of whites, 18 percent of blacks, and 31 percent of Hispanics had no health insurance , a clear instance of social factors—among them, race—influencing individual health. Clean air, safe drinking water, adequate housing, and sufficient food are instrumental in promoting health. Can you be healthy in a war-torn country or drinking water downstream from a coal ash dump?
As a medical student in Detroit caring for a hospitalized asthmatic child, I learned that she had been hospitalized numerous times and that her asthma was triggered by fighting in her home. She needed acute treatment for her asthma, but to prevent future exacerbations, her family also needed help in managing the strife caused by poverty. Was that a role for her doctor? I was taught that as medical professionals we should take a broader history and help her family by providing social supports in the same way that I was taught to make sure that her family had the money (or insurance) to purchase her medicines or that, too, would cause her to be right back in the emergency room. These are examples of the role of individual patient advocacy.
Without being advocates for our patients we cannot address their health status or their illnesses adequately. Social conditions of poverty, lack of nutritious food, interpersonal violence, and racism affect health more than infectious disease agents.
It is but a short step, then, to evaluate the community and identify conditions that only public advocacy will ameliorate. Advocating for adequate housing, for example, can improve health. City planners in Salt Lake City found that it was also cost-effective to provide free housing to those who were homeless rather than pay the health and social bills .
Historically men and women in medicine have been sought out to redress social conditions that contribute to illness. Physician and scientist Rudolf Virchow was sent to evaluate a Prussian community devastated by typhus, a bacterial disease carried by lice. He found severe malnutrition due to drought unrelieved by governmental support. Virchow did not advocate treatment of medicine to kill the typhus organism or even measures to kill the lice, but outlined a revolutionary program of social reconstruction including full employment, higher wages, the establishment of agricultural co-operatives, universal education, and the disestablishment of the Catholic Church, which basically ruled Prussia at the time . This is not unlike the current situation in Syria, where residents suffered four years of unremitting drought due to climate change. In a country that is normally able to feed itself, three million people had inadequate food, and one million were driven from their land . The government’s response to protests—to which climate-related resource scarcity had contributed—led to a civil war . To reduce the likelihood of additional strife in Syria and elsewhere, physicians will be instrumental in advocating for reversing the causes of climate change and preparing our communities for its known impacts.
Health professionals have the skills to be excellent advocates. They are trained to seek causes of illness and demand evidence to evaluate treatments. This leads them to understand that solutions advocated for social ills should be evaluated and proven effective as well. Most can translate scientific complexities such as diagnoses and treatments into layman’s terms and have the ability to communicate complex issues. In general, physicians are respected and have access to policymakers and the opportunity to influence public thought and public will.
Are physicians concerned that the coal plant upwind of my former patient’s home and the homes of many others in that poor neighborhood of Detroit are adding to rates of asthma and accelerating climate change? The American Medical Association exhorts that physicians “advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being” . Likewise, the American Academy of Pediatrics states that its organization “was founded by pediatricians to help ensure that patient advocacy remains a priority for the profession” .
Advocacy skills, however, need to be taught. Being an advocate requires that an individual believes he or she can effect change, is motivated to do so, and is able to envision what improvements are needed and how they can be instituted. Many incoming medical students want to improve access to health care for individuals because they can readily see that care for patients is inadequately provided in the US system. I have witnessed many young health professionals become empowered to take action addressing the underlying causes of disease, while still learning how to address acute medical disease in their patients. Both are exciting and both need to be taught.
There are sometimes advocate role models within medical schools who lead students by example, giving them the vision and empowering them to effect change. These role models provide and advocate for solutions such as free clinics or insurance reform. Without specific instruction however, the vast majority of students do not learn about the role of physicians as advocates.
Program development to provide advocacy skills training is now occurring in some locations; unfortunately it is still the exception rather than the rule. Wayne State University offers an elective called Medicine and Political Action in the Community . Some residency programs, such as those at Thomas Jefferson University Hospital  and UCSF’s Physician in Society Rotation , focus on these topics as well.
Advocacy can be as simple as voting for officials who will take the social determinants of health seriously or sending an email to an elected official. But it can be as complicated as suing the EPA to create a rule to limit greenhouse gas emissions, arguably the greatest threat to public health of this century. There are actions that can be taken by individuals and those that require organizations.
All citizens of this country have many rights. One can argue that they also have responsibilities. One of those responsibilities is to make their community or “world” a better place. Doctors are not exempt. The advocacy training I received in medical school has translated to a lifetime of practice. I believe all physicians could provide much more benefit to public health if they receive advocacy training early in their careers.
World Health Organization. Social determinants of health. http://www.who.int/social_determinants/en/. Accessed July 30, 2014.
Kaiser Family Foundation. State health facts: uninsured rates for the nonelderly by race/ethnicity. http://kff.org/uninsured/state-indicator/rate-by-raceethnicity/. Accessed July 30, 2014.
Wogan JB. How Salt Lake City solved chronic veterans homelessness. Governing Magazine. December 9, 2013. http://www.governing.com/news/headlines/gov-how-salt-lake-city-licked-veteran-homelessness.html. Accessed June 1, 2014.
- Brown TM, Fee E. Rudolf Carl Virchow: medical scientist, social reformer, role model. Am J Public Health. 2006;96(12):2104-2105.
- Gleick PH. Water, drought, climate change, and conflict in Syria. Weather Climate Soc. 2014;6(3):331-340.
Plumer B. Drought helped cause Syria’s war. Will climate change bring more like it? Wonkblog. September 10, 2013. http://www.washingtonpost.com/blogs/wonkblog/wp/2013/09/10/drought-helped-caused-syrias-war-will-climate-change-bring-more-like-it/. Accessed July 30, 2014.
American Medical Association. Professionalism and human rights: AMA Declaration of Professional Responsibility. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethics-group/institute-ethicsresearch-projects/professionalism-human-rights.page. Accessed June 1, 2014.
American Academy of Pediatrics. Advocacy and policy. http://www.aap.org/en-us/advocacy-and-policyPages/Advocacy-and-Policy.aspx. Accessed July 24, 2014.
Wayne State University School of Medicine. Medicine and political action in the community. http://www.mpac.med.wayne.edu. Accessed June 1, 2014.
Nemours Children’s Health System. Advocacy training system (JeffSTARS). http://www.nemours.org/education/gme/pediatricresidencyadvocacy.html. Accessed June 1, 2014.
UCSF School of Medicine Department of Pediatrics. Education and fellowships. http://pediatrics.ucsf.edu/pediatric-specialties/general-pediatrics/education-fellowships. Accessed June 1, 2014.