On the surface, the causes of many health problems in the U.S. seem apparent. But a deeper look reveals that many diseases and ailments have far more complex origins that are often rooted in social and economic inequities.
In 2000, more than a half million deaths were attributed to heart attacks, strokes, and lung cancer; however, a National Institutes of Health (NIH) study paints an alarmingly different picture. Researchers found that of the above- mentioned deaths, 245,000 were attributable to low education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual- level poverty, 39,000 to area-level poverty, and 119,000 to income inequality. Although the link between such social factors and poor health is complicated, the study’s authors say “evidence points to mechanisms including risky health behaviors (e.g., smoking), inadequate access to healthcare, poor nutrition, housing conditions, or work environments.”
[Above: Above: Creighton University dental students educate children at Nelson Mandela Elementary School on proper dental hygiene.]
“Negative social interactions, including discrimination, have been linked to elevated mortality rates, potentially through adverse effects on mental and physical health as well as decreased access to resources,” the report says. “Finally, characteristics of one’s residential environment may influence mortality through investment in health and social services in the community, effects of the built environment, and exposure to violence, stress, and social norms that promote adverse health behaviors.”
Overall, NIH’s findings indicate the need for “a policy approach that considers how social factors can be addressed to improve the health of populations,” the researchers concluded.
Recognizing the link between societal and economic circumstances and public health, healthcare professionals have advocated for an increased focus on social justice in medical fields. In an article titled “A Call to Service: Social Justice Is a Public Health Issue,” published in 2014 in the AMA Journal of Ethics, authors Martin Donohoe, MD, and Gordon Schiff, MD, posit that physicians have much to learn from their patients’ struggles with poverty, sexism, and racism.
“We have a responsibility to grapple with the conditions our patients face,” they wrote. “Caring deeply for and about our patients should naturally lead us to contemplate how we can help them in the broadest and most effective ways — ways that would entail ameliorating their problems through a public health approach to practicing medicine.”
On medical school campuses across the country, students are beginning to take an active role in illuminating and working to address the social injustices that underlie some of the most pressing health issues faced by Americans. For instance, following the election of President Donald Trump, a group of Yale medical students known as the Yale Healthcare Coalition launched the national #ProtectOurPatients campaign to oppose the repeal of the Affordable Care Act — an action that is likely to strip millions of health insurance coverage — and advocate for a bipartisan approach to improving the law. Since it began, the campaign has gained nearly 5,000 supporters across 150 medical schools in every state. Another movement to raise awareness of healthcare-related injustices is WhiteCoats4BlackLives, a medical-student-led movement aimed at raising awareness of racism as a public health concern, ending racial discrimination in medical care, and preparing future physicians to be advocates for racial justice.
For Isaac Edwards, a student in the University of New Mexico (UNM) School of Medicine, social justice means examining the inequalities that “exist throughout everyday life” that relate to race, gender, or human rights. “Social justice is putting a magnifying glass on those things and deciding what is ethical and right,” he says.
His classmate, Lucia Xiong, agrees, adding that a proactive approach to healthcare means better outcomes for more people. “If people are jumping off a bridge into a river and you are downstream just catching them, then you’re really missing the root cause,” she says. “[In the long run,] it’s a lot easier to fix [the problem] than to catch individuals one by one.”
Detriments to Health
At UNM’s School of Medicine, although societal and public health issues have long been addressed by faculty and students, a focus on social injustices is a relatively new component of the curriculum, says Felisha Rohan- Minjares, MD, an associate professor in the Department of Family and Community Medicine. Physicians, she says, must understand the effect that an individual’s environment has on his or her health and actively work to improve those conditions.
“If they are not taking that into consideration, no matter how many CT scans they order, no matter how many prescriptions they prescribe, they’re not going to have a lasting effect on [patients’] health if their social conditions are difficult or unchangeable,” says Rohan-Minjares. “I think physicians have an opportunity to be leaders and … claim an active role in advocating for things like better education and economic equality because we know those things are directly linked to health.”
Addressing social conditions begins with education and understanding. At UNM, beginning with their first semester and throughout their education, medical students learn about the social and economic injustices that affect health. During the first two weeks of school, students take a class that focuses on public health and social detriments in New Mexico — a state fraught with health disparities, according to Rohan- Minjares.
“Being the only medical school and academic center in a state that is underserved and under-resourced,” she says, “we see vast inequities and injustices that impact the health of our patients.”
In students’ third year, during their family medicine clerkship, they are required to do a community service project designed to get them to think critically about health disparities and possible policy solutions. Similarly, in year four, they conduct research to identify a healthcare issue and “learn about the politics and economics behind it and try to come up with a viable solution,” Rohan-Minjares says.
Edwards and Xiong say they have also learned a great deal about historical events and trauma, as well as human rights violations, which have had long-term consequences for underrepresented groups. Topics have included everything from the increase in diabetes in Native American communities due to minimal access to healthy foods on reservations, to the spike in cortisol levels in African Americans after being brought to the U.S. as slaves. Furthermore, a new course, added to the curriculum in April, engages students in discussions about race and racism and how they affect health. All first-year medical students must complete the class, which Rohan-Minjares says is designed to explore racism in a more deliberate way.
To give students hands-on experience with New Mexico’s underserved populations and the injustices they face, and to improve students’ ability to deliver culturally effective care, the school facilitates opportunities to work in local communities. Through a variety of free clinics, students volunteer to serve patient populations composed primarily of homeless people and Spanish-speaking Mexican immigrant workers, says Rohan-Minjares. “They engage in work that gives them a real- life demonstration of what it means to be a patient in communities in our state that are underserved,” she says.
The UNM School of Medicine Rural and Urban Underserved Program also provides opportunities for students to treat patients in medically underserved areas of New Mexico. Designed to support, mentor, and prepare students to serve these communities, the program also allows them to participate in seminars on healthcare topics and assist faculty members with scholarly work focused on health problems in underserved areas. “We [have] weekly seminars where a lot of these topics — such as food and security or substance use problems — are addressed,” says Xiong, who participates in the initiative.
“We want them to go away with the skills to think about how to impact these issues,” Rohan-Minjares says. “Social justice is a core value that I would like to see all of our medical students graduate with — this idea that part of being a doctor is being part of a solution to the health problems that our state and our nation face.”
In Omaha, Neb., the belief that awareness of the injustices that different groups face requires interaction with those communities drives Creighton University School of Dentistry’s approach to dental education. “To try and understand where people are coming from, you have to go where they are,” says Kim McFarland, DDS, chair of the Department of Community and Preventive Dentistry and a professor.
“One of the things that makes us unique is that we provide a variety of experiences for students to engage with the world during their training,” she adds, “and we really focus on underserved and, in some instances, marginalized populations and what we can do to make a difference.”
McFarland says Creighton’s dental program can be broken down into three elements: preparation, hands-on experiences, and reflection. Prior to going out into the community, students learn about the populations they are going to serve — their culture, language, socioeconomic situation, and the barriers they face to good health. Students are then encouraged to reflect on their experiences to think critically about the needs of the communities they’re helping.
With nearly 10 sites to choose from, students gain both hands-on dental experience and exposure to many segments of the population, as well as knowledge of their differing challenges and needs; sites include a refugee center, homeless shelter, Indian reservations, a Head Start program, and an adult day care for the elderly. Additionally, the School of Dentistry partners with the Nelson Mandela Elementary School — a free private school for low-income children — to provide dental services.
With a goal of having all the children cavity-free by 2023, Creighton students conduct annual screenings, a fluoride varnish program, and dental sealants at the elementary school.
Community engagement is not a one-time thing for Creighton’s dental students, says McFarland, and this work only increases as they progress through the program. But for as much as the school prepares them to enter underserved communities, real-life situations often provide the best — albeit more formidable — learning experiences. What students learn in the classroom is not enough, as competing life circumstances often muddy the waters, McFarland says.
“We tell people they need to eat fresh veggies and [have] healthy diets, but … [they’re on] the Indian reservation, and it’s 20 miles to the nearest grocery store — and who has the gas money to drive 40 miles round trip?” she says.
“I can give the textbook solution for that situation, but you need to have a social awareness of the dynamics in that home. [You have to] get beyond some of the noise, beyond the superficial, and really start to understand the community in a larger context.”
While doing fillings, cleanings, and extractions can become monotonous, getting out into the community and making a real difference is what McFarland finds to be the most stimulating aspect of healthcare professions. She believes that, over time, witnessing the injustices and inequities that people face will make students more passionate about correcting them.
Back at UNM School of Medicine, Edwards and Xiong founded a student group called the Social Justice Initiative, through which they work to share knowledge with the campus community about the social injustices experienced by certain populations. Last year, the group partnered with the Student National Medical Association to host a WhiteCoats4BlackLives event. Faculty, students, and hospital staff from the UNM Health Sciences Center attended and shared their experiences with inequities in healthcare and their personal lives. Xiong says it was designed to “highlight that these issues are not just affecting our patients, but also us as providers.”
“All of these issues surrounding safety and a broader vision of what being healthy means — being at low risk for becoming a victim of violent crime, for instance — those are issues that are on the minds of students,” says Rohan-Minjares. “Many of UNM’s students are socially conscious and often seek opportunities to serve those that they see as being disenfranchised and underserved.”
As the diversity of the population increases, it’s likely that health inequities and disparities will persist. For McFarland, this makes interacting with diverse and underserved groups all the more important.
“I tell students, if you want to see who is going to be sitting in your dental chair in about 10 years, look at the enrollment in public schools,” says McFarland. “We’re going to have a tsunami of different languages, cultures, and needs in the dental office, so these experiences of taking students out into the community and starting to build some of [their] knowledge, skills, and abilities are really critical.”
Fortunately, the movement to increase the focus on social justice in medical education is gaining momentum. For example, the Liaison Committee on Medical Education (LCME), the federally recognized accrediting body for medical education programs, now requires that schools address societal problems and healthcare disparities in their curricula. “These topics are required because future physicians must understand medicine and healthcare delivery within a social context and accept responsibility for working effectively with appropriate teams of individuals to promote the best possible outcomes,” says Veronica Catanese, MD, co-secretary of the LCME.
Further emphasizing the importance of a social justice approach to public health, the UNM School of Medicine considers students’ interest in these issues in the admission process.
“When students are interviewed for admission to our school, we want to know if they understand the issues that are present in the healthcare environment of our patients and if they care about those. We are looking for people with an interest in those issues and a desire to make a difference,” says Rohan-Minjares, adding that an inherent affinity for social activism is vital to the healthcare professions. “Promoting social justice should be core to the identity of every physician.”●
Alexandra Vollman is the editor of INSIGHT Into Diversity.