A guest column by the American College of Physicians, exclusive to KevinMD.
The recent occurrence of widespread civil unrest in the context of the coronavirus pandemic has challenged us as physicians about our appropriate role in dealing with both.
The response of doctors to the pandemic has been fairly straightforward. The central role of individual physicians and the entire medical profession in confronting a new, highly contagious and dangerous infectious disease on a global scale, even when exacerbated by significant social and political factors, is clear. But addressing issues related to social inequity is an uncomfortable proposition for many physicians.
Why is this? In my conversations with colleagues, some express the belief that these types of complex, less tangible problems extend beyond the boundaries of the medical profession; that they are more administrative and political in nature and should be dealt with from that perspective. In fact, a number feel strongly that the physicians’ primary commitment should be only to the care of individual patients, and that it may be inappropriate or even detrimental for doctors to engage around issues that could potentially be seen as polarizing and risk alienating them from those for whom they care and their colleagues.
Yet, we are witnessing the real effects of social inequity on the health of our patients as dramatically surfaced by the pandemic and seen in the inordinate impact of COVID-19 on different racial and ethnic segments of our society, and violence directed at certain minority groups in our country. So what should the appropriate response of the medical profession be?
As physicians, we understand that true health is dependent upon the complex interplay among an array of genetic, lifestyle, and environmental factors. Even as far back as the time of Hippocrates, it was recognized that disease is intimately tied to individual characteristics influenced by imbalances in diet or personal behaviors as well as the nature of the world in which patient exists. Thus, even at this early time in the history of medicine, it was seen that the ability to prevent and treat disease and achieve overall health requires that we consider more than each patient in isolation.
Today we term these external influences as social determinants of health, defined as the conditions into which people are born, grow, work, live, and age, as well as the wider set of forces and systems that shape the conditions of daily life. They are wide-ranging and include factors such as access to safe housing, food, educational, economic and job opportunities, and health care services; language and literacy; socioeconomic status; public safety and social and community support; access to technology; and social norms and attitudes including discrimination and racism.
And an increasing body of research has shown that the impact of these social determinants on overall health is incredibly powerful, with some studies suggesting that actual direct medical care may be responsible for as little as 20% of preventable mortality in the US, with these other factors accounting for the balance.
Much as we are seeing a striking difference in clinical outcomes in certain racial and ethnic groups with COVID-19, the differences in clinical outcomes for other non-infectious diseases such as diabetes, cardiovascular disease, cancer, and kidney disease, particularly among African-American, Native American, Hispanic, Asian-American, and Pacific-Islander populations have been extensively documented. It is also well-known that discrimination, harassment, and violence that also disproportionately affect these groups have a profound influence on overall health and are associated with greater risk for poor mental and physical functioning, unhealthy behaviors, decreased utilization of care, and non-adherence to medical regimens.
Given what we know, it is therefore imperative that physicians recognize that what we are seeing in the pandemic and civil unrest are actually reflections of these underlying social determinants that are negatively impacting the health of a large number of members of our society.
Interestingly, most physicians understand the influence of social determinants on health outcomes. However, recent surveys have shown that even though most clinicians agree on their importance, many say it is not their responsibility to address them. And for those who do feel it is their responsibility, most do not feel empowered or equipped to do so.
Yet, our ethical commitment as physicians is to treat all patients equally and provide the best medical care possible irrespective of who they are and the circumstances in which they exist. Therefore, in order to address the disparate treatment of our patients, we must start by recognizing our own individual assumptions related to culture, ethnicity, and the many other overt and intrinsic factors that might contribute to the differential treatment of different groups of patients. We need to hold ourselves, our colleagues, and our systems of care to the high standards and principles that underlie medicine as a profession.
But just as importantly, as physicians, we also have a moral obligation to seek societal change to address these “non-medical” yet incredibly powerful influences on our patients’ health, regardless of how difficult and personally uncomfortable doing so may be. Only by bringing to bear the collective power of medicine to illuminate the impact of these adverse social determinants on patients and strive to rectify them will we be able to treat the whole person and achieve the well-being we seek for all under our care.
What we are experiencing is an individual patient issue. But it is also a public health issue. And it is why physicians must speak out about social inequity.
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