Congratulations to the medical students who completed the 5th annual HHRA course, held September to December 2014. The final class was an opportunity to review the concepts discussed over the last few months and reflect on the way medical students and health professionals can be actors of change in their own lives and careers.
A summary of the discussion by session follows:
Health and Human Rights in East Harlem: Ray Cornbill urged students to continue taking a systems-level view in our work and understand hospitals as comprised of departments or practices with vastly different policies; for example, clinics within the same hospital may have vastly different policies regarding insurance mix. We examined East Harlem and the multitude of health services that are available there. In doing community work, he pointed out that often the best course of action is to make the existing systems work more efficiently — strengthen the glue — rather than adding another program to the mix. When conducting research, we were encouraged to examine our methods and consider who exactly benefits from much of the research we conduct and the ‘production’ of medical knowledge. Here, he was especially critical of needs assessments. Why do we fashion needs assessments before intervening? How many does it take to actually meet a need? What is the obligation to follow up — and whose is it?
Legal Framework of Human Rights: Brian Tronic helped us zoom out even more and help us understand the legal framework behind human rights at the international level and how difficult it can be to do human rights work at the international level. We examined existing core human rights covenants, paying particular attention to which ones the US has signed and which it has not (Civil and Poltical, Yes; Economic Social and Cultural, No; Against Torture, Yes; Elimination of all forms of Racism, Yes). We discussed that international human rights work mostly draws legitimacy from the field of law, but that laws themselves are created to codify cultural values; and we discussed accountability for protection and violations of human rights principles.
Mass Incarceration: DOH correctional services medical directors Zach Rosner and Ross Macdonald introduced us to the scale of what public health researchers call ‘the epidemic of mass incarceration’ and the ways it targets and devastates the health and well being of poor black and brown communities. They highlighted the conflicting priorities of health and punishment, with criminal justice institutions in this country abandoning any goal of rehabilitation in favor of containment and controls, and how these conflicting priorities manifest in dual loyalty considerations of prison health care workers. They made sure we all understood the difference between jails (which hold people pre-trial or pre-sentencing or for minimal sentences) and prisons (which hold sentenced people), and they introduced some of the cost cutting practices of governments of hiring private contractors to manage the health care of people in jails and prisons, who themselves hire the cheapest health care providers available and willing to take on the job. They also described the particular brutality of the use of solitary confinement at Rikers, where non-convicted teens and adults who simply cannot pay bail may end up serving 3-5 years in confinement, and in which people become 7x more likely to commit acts of self harm. Rikers jail holds more mentally ill people than all state hospitals combined.
Structural Competency and Community Psychiatry: Helena Hansen explored the need for critical thinking skills as a part of — or sometimes applied towards — our medical education. She emphasized the importance of reflexively de-naturalizing your own cultural assumptions by learning the history of the profession, the political and economic forces shaping our approach to health problems, and which framework of ‘body’ and ‘illness’ underlie our method. For example, we discussed why medicine currently focuses a focus on behavior management and compliance rather than patient circumstances, environment etc… She challenged medicine’s presentation of ‘culture’ as a bound variable that an individual may master through ‘cultural competency’ training. She introduced the conceptual alternative of ‘structural competency,’ bringing the logic of public health into clinical practice by considering the role of structures — institutions, communities, policies, i.e. health insurance plans, war on drugs policies, policing methods, redlining. Thus, she argued we should pursue interventions that are beyond the level of the individual encounter and identify cases of institutional racism. Her use of institutional racism referenced the words of Stokeley Carmichael in 1968 who protested the silent racism of “established and respected forces in the society” that functioned above the level of individual perceptions or intentions and worked to maintain the status quo — a racism that is less overt, more subtle, and less identifiable, but no less destructive to human life.
Insurance Inequalities and Physicians for a National Health Plan: David Himmelstein spoke specifically about instituting a national health plan, and what this would entail for our country. He spoke about the underlying idea in our current system of health as a commodity, highlighting the first question a patient is asked in the hospital, which is not “what is your complaint,” but “what is your insurance.” To demonstrate what change might look like, he proposed treating hospitals like fire stations, giving each a lump sum of money based on public funds with which to take care of sick people. To take the analogy further: it doesn’t matter what the size of the fire is, or what tools you will need to fight it, because you still have to deal with the problem before it burns uncontrollably. So where does change begin? Dr. Himmelstein was actually rather optimistic, and reminded us that in the 60s people largely recognized mass organizing as the roots of change. But do we still feel this way now? And if not—why? Do we advocate for an imperfect health system, like the ACA, even though it does represent progress for many? In the actions we consider, we must also remember how history is often rewritten to disregard mass organizing around issues like this, so that we are satisfied with the political process as it stands: he reminded us, “Politicians by and large don’t lead. They follow.”
Transgender Health: Dr. Jeff Birnbaum discussed the creation of the category of “gender dysphoria” in the DSM-5, which attempts to remove the stigma of the term “disorder” while continuing to ensure that transgender/intersex individuals are able to access hormone therapy, psychotherapy, etc under insurance – and yet, this categorization remains in the DSM. Although there may indeed be good intention in protecting transgender individuals’ access to care, the inclusion of their lived experience in a manual of mental disorders is problematic and stigmatizing. How, then, can we ensure that people may access the care and therapy they need, without encasing them within a set of criteria? Then, Dr. Birnbaum spoke extensively about his journey as a physician – first treating HIV/AIDS and gradually became an advocate for transgender youth regardless of HIV status. His story exemplified a doctor who allowed himself to be pulled to where he was needed, and one who has let his patients define what protocol is needed for their treatment. Dr. Birnbaum also spoke about the White Coat. The White Coat can be a symbol of our expertise and can build our “prestige” among our peers or policymakers – in other words, it can be a useful tool in certain situations. However, in dealing with patients, it is important to remember that the White Coat can be a barrier of apparent expertise. As physicians, we need to allow ourselves to be wrong, allow ourselves to be open, and recognize that while we may be educated in terms of disease processes or the mechanisms of pharmacologic therapy, we are not experts in the patients’ subjective experiences of disease or suffering. Terms: gender dysphoria versus disorder; gender; sexuality; access to care; lived experience; stigma; White Coat; expertise; barrier;
Sexual Violence: Angela Fernandez and Lynn Frederick-Hawley from SAVI reminded us that one can be an agent of change locally. In the field of sexual violence, you can be an individual that promotes the restructuring of regulations in colleges, becomes a volunteer advocate in the emergency room, and speaks against victim blaming in your day-to-day conversations. But what about when violence becomes normalized? In our small groups, we were asked to consider the spaces (not so far from us) in which sexual violence is brought to light—e.g., privileged college campuses—and those in which the individuals affected do not have the power or means for recourse. So part of our responsibility as advocates is to consider who is visible, and who is invisible, and to address that widening gap.
Palliative Care: Dr. Diane Meier’s talk was extremely intense and extremely relevant for MS1s and MS2s. During our clerkships, we may very well see patients treated just as she described – with desperate attempts to save a life, yet with little attention paid to the manner and quality of death. This is an example of the “hidden curriculum” of medical education: the practices, behaviors, and ways of seeing/treating patients that are implicit, that we learn throughout medical school without being explicitly “taught”. In thinking about we can do to overcome the power of the hidden curriculum, it is important to remember that we are not alone in resisting and seeing that something is wrong – you are not crazy. Secondly, we do not have to ignore death and dying, or hide ourselves from it. As one student said, there are ways to hold conversations about death and dying, and we can learn those skills. Discussions like these — with the growth in palliative care programs — have indeed improved the quality of life for patients with terminal illness (reducing suffering and pain, improving their capacities to live the life they want and die with dignity) and have actually extended patient’s lives. Finally, we can choose – as medical students, residents, physicians – to actually listen to patients rather than make value judgments based on behaviors we see as contradictory or counterproductive. Terms: save a life; quality of death; hidden curriculum; palliative care; listen; posturing; dignity; meaning-making; pain; capacity; live the life you want
The course ended on a few broad questions: When do you put your head down and plug through? When do you allow people and ideas to inspire your actions toward change? Where do we get the power to resist — power in communities, power and students.