Chapter 21: Why Doctors Need to be Politically Engaged...and Engaging
By David Werner
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.
"I spent nearly everything I had to pay the doctor," she said, "and cant 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 ore 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.
The good news is that the baby was finally successfully treated at about 1/20 of the cost of medicines that 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 afford it.
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 that constitute about 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.
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 theyd befriended cope with their health-related problems as best they could. Because most families were large, during that first year of medical school the students provided basic health services, information and advocacy to more than 10,000 underserved people!
In 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. 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 programme had begun, the death rate among young children -- which had initially 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.
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 the workings of a project that reintroduced 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 the general health of their children.
One mother said, "We use homemade remedies to cure a lot for our childrens ailments, and most of them get well."
Other mothers pointed out that, thanks to their 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 were saying?" exclaimed a mother. "Were saying it was medical care that was killing our children! What we spent on the doctors 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 nestling beside her said, "So at last we know why our children are healthier! Now weve 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 couldnt 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 `rich 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:
Allocation of resources. In todays globalised economy, Death apparently has greater value than Life. Governments spend far more on the instruments of war, arms and armaments 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 most.
The need for universal health care. Doctors who are health literate, and want to become politically engaged, would to do well to join the forces that are demanding universal health coverage, so that families will no longer be at risk of having illnesses ruin their lives.
Everyone should have equal access to basic resources such as adequate calories, clean water, good sanitation and unpolluted air in order to sustain good health. The World Water Council reports that more than one out of six people lack access to safe drinking water. Thats 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.