Only by understanding inequality can clinicians start to heal their patients and communities, write Utpal Sandesara, Lauren Kelly, and Adeline Goss
Doctors can’t solve inequality, so why should they try?
So goes the argument of an essay written by our medical school’s former dean of curriculum back in April. Writing under the headline “Med School Needs an Overhaul: Doctors Should Learn to Fight Pandemics, Not Injustice,” Stanley Goldfarb advocates for gutting “social and organizational topics” from medical school curricula. He argues that teaching students about these subjects distracts from necessary training in areas like pandemic response and critical care. “The medical profession,” Goldfarb maintains, “should abandon the fantasy that physicians can be trained to solve the problems of poverty, food insecurity, and racism.”
We have heard the argument that doctors need to “stay in their lane” before. And it has never been more wrong than now.
Covid-19 has acted for months as “the great unequalizer,” ravaging the world’s most vulnerable communities. More recently in the US, the long history and ongoing reality of racism against black people has once again resulted in violence with the brutal killings of Breonna Taylor, Ahmaud Arbery, and George Floyd.
Critical care textbooks do not contain solutions to the interpersonal and systemic injustices that create unequal health outcomes for black and brown people. If we wish to effectively tackle emergencies like those facing us today, we must strengthen—not curtail—doctors’ understanding of the social, economic, and political factors that shape health. Medicine will always be social, and even more so in times of crisis.
The call to pare back these subjects in medical school rests on the assumption that medicine is entirely applied biology. In this view, doctors should operate exclusively as scientists and technicians, avoiding the muddy world of lived reality. But it is foolish to imagine we can separate a person’s individual biology from their connections to their family, community, and environment. When we sever individuals from their surroundings, we end up ignoring the social determinants of health—factors like economic stability, physical environment, education, food security, and social support—that in fact determine a majority of variation in health outcomes.
As physicians, we must recognize social determinants as powerful risk factors for poor health outcomes—as important as any biomarker or abnormal lab result. We must learn to treat social determinants as active dangers to health, in the same way we treat smoking cigarettes as harmful to the body. Above all, we must learn the tools to heal the wounds they cause.
Covid-19 has confounded any claim that social problems are not the problems of the healthcare workforce and the larger healthcare system. Like HIV/AIDS, Ebola, and other infectious epidemics, the novel coronavirus has preyed on and exacerbated underlying inequality. Race and ethnicity profoundly influence who gets sick, and how severely. Black and Latinx people bear a far greater burden of illness and death than their white counterparts. Across the US, residential segregation makes a person’s postal code a significant predictor of morbidity. Racial and economic inequity means that patients from the communities hardest hit by coronavirus paradoxically face more challenges in accessing testing, leading to misdiagnosis and preventable death. Blue collar jobs like meat packing carry serious risks for workers, who often have little choice in matters of distancing or other precautions.
Physicians can only provide good care if they can anticipate and address these inequalities. Awareness of systemic injustice allows us to empathically approach the critically ill breadwinning grandfather of a large immigrant family or the undomiciled patient who fears a decline when he returns to his homeless shelter. It permits us to recognize and address our own biases. It motivates us to look for solutions, like free access to and equitable allocation of essential testing and treatment, greater protections for laborers at risk, prison health reform, policies preventing utility suppliers from cutting off people who are vulnerable, funding for nutrition programs, and guarantees of secure housing.
In the end, if we have fallen short in our care of covid-19 patients, it will not be because we lacked training in emergency intubation or ventilator management. It will be because we failed to confront the pandemic’s social and ethical challenges—precisely the kinds of challenges that medical education needs to prepare us for.
More broadly, social education in medicine can sensitize medical trainees to public health crises like the epidemics of police violence and mass incarceration in the US. Police use of force is a leading cause of death for young black men, as well as a major contributor to individual and collective trauma. Compared with white men, black men face higher rates of imprisonment and longer sentences for the same crimes, producing greater exposure to the detrimental health effects of incarceration.
Physicians with a critical approach to the social world are more likely to speak up about the health effects of violent law enforcement. Following the death of George Floyd, the American Medical Association denounced racialized police brutality, and the American Academy of Ophthalmology condemned the use of rubber bullets to quash peaceful protests. These are just two recent examples. Work by the student-led group White Coats for Black Lives illustrates how medical student advocacy for racial justice can be impactful and enduring.
Without an understanding of the personal, interpersonal, and structural dimensions of racial inequality, clinicians cannot adequately address what ails our patients and our communities. We cannot comprehend why suffering follows such predictable patterns, or how we must go beyond individual technical solutions to heal systemic pathologies. At a time of widespread public health crisis, as leaders at the highest levels sow civic discord, medical schools should teach students to fight for care and safety for all.
This is why the Centers for Disease Control and Prevention is compiling resources on covid-19 in minority groups. It is why academics are insisting we contextualize the pandemic’s racial disparities in relation to social factors like poverty, chronic stress, and location. It is why physicians are calling for an end to police brutality, and why medical students are demanding we address it directly in medical education.
Why should doctors bother grappling with injustice? Because doing so will save lives. Understanding inequality will help us confront today’s crises—and prepare us for whatever comes next.
Utpal Sandesara is a resident physician in internal medicine at UCLA.
Lauren Kelly is a resident physician in internal medicine at Cornell. Twitter @WIDLML
Adeline Goss is a resident physician in neurology at UCSF. Twitter @addiegmd
All three graduated from the University of Pennsylvania’s School of Medicine, where they were involved in social medicine curriculum design.
Competing interests: The authors have read and understood BMJ policy on declaration of interests and declare the following interests: None.