Activism in Medicine: History, Literature, and Contemporary Issues and Movements

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• Activism in Medicine History, Literature, and
  Contemporary Issues and Movements
• Martin Donohoe

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Overview

• Background
• Issues
• History
• Literature
• Quotes and Photos
• Education, the media, and democracy
• What you can do

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Portland, OregonMount Hood
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Multnomah Falls, Oregon
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Am I Stoned?

• A 1999 Utah anti-drug pamphlet warns
• Danger signs that your child may be smoking
  marijuana include excessive preoccupation with
  social causes, race relations, and environmental
  issues

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Harvey Cushing

• A physician is obligated to consider more than
  a diseased organ, more even than the whole man.
  He must view the man in his world.

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Medicine and Public Health

• Schism between the fields
• Witnessed victims vs. statistical victims
• Precautionary Principle

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Important Historical Figures in Medicine/Public
Health and Social Justice

• Florence Nightingale
• Margaret Sanger
• Albert Schweitzer
• Charles Dickens
• George Orwell

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Important Historical Figures in Medicine/Public
Health and Social Justice

• Upton Sinclair
• Anton Chekhov
• William Carlos Williams
• Thomas Hodgkin

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Important Contributions of Public Health

• Water and food safety
• Sanitation
• Vaccination
• Fluoridation
• Iodine supplementation of table salt
• Seat belts, air bags
• Bed nets for malaria prevention
• Barriers to decrease bridge suicides

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Rudolph Virchow

• Founder of modern pathology
• Thrombosis, pulmonary embolism, leukocytosis,
  leukemia
• Member of state and local government for over 30
  years
• Founded journal Medical Reform

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Rudolph Virchow

• Argued that many diseases result from the
  unequal distribution of civilizations
  advantages
• Advocated public provision of medical care for
  the indigent
• Promoted universal education

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Rudolph Virchow

• Worked to outlaw child labor
• Improved water distribution and sewage system
• Enhanced food inspection process
• Published study of skull volumes to dispute myth
  of larger Aryan brains

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Rudolph Virchow

• Passed hygiene standards for public schools
• Set new standards of training for nurses
• Improved local hospital system

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Rudolph Virchow

• Doctors are natural attorneys for the poor If
  medicine is to really accomplish its great task,
  it must intervene in political and social life

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Issues

• Access to care
• Boutique medicine
• Racial, sexual and SES discrepancies in outcomes
• Homelessness
• Effects of poverty on health
• Hunger

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U.S. Health Care

• Per capita expenditure on health care
• U.S. 4,000
• Typical poor African/Asian country 5-50
• Even so, U.S. has 47 million uninsured, ranks
  24th worldwide in overall population health as
  judged by disability-adjusted life expectancy

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Headline from The Onion

• Uninsured Man Hopes His Symptoms Diagnosed This
  Week On House

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Racial Disparities in Health CareAfrican-America
ns

• Higher maternal and infant mortality
• Higher death rates for most diseases
• Shorter life expectancies
• Less health insurance
• Undergo fewer diagnostic tests / therapeutic
  procedures

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Issues

• Excessive pharmaceutical company influence,
  dubious marketing practices
• Womens rights issues
• Violence against women
• Access to reproductive health care
• Female genital cutting
• Political, legal, and educational marginalization

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Status of Women

• Economic discrimination
• Women do 67 of the worlds work
• Receive 10 of global income
• Own 1 of all property
• A woman in a developing country walks an average
  of 6 km/day to obtain water

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Issues

• Environmental degradation
• Overpopulation
• Air and water pollution
• Toxins
• Deforestation
• Global warming

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Issues

• Environmental degradation
• Unsustainable agricultural and fishing practices
• Famine
• Commodification of worlds food and water supply
  by corporations
• Species loss

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Poverty Worldwide

• 1.1 billion people lack access to safe, clean
  drinking water
• 1.8 million child deaths/year
• 2 billion have no electricity
• 2.6 billion do not have adequate sanitation
  services
• Hunger kills 18,000 people per day, most under
  age 5

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Consequences of Pollution

• Air pollution causes approximately 60,000 -
  75,000 premature deaths/yr. in U.S., 1.8 million
  worldwide
• NAS Pesticides in food could cause up to 1
  million cancers in the current generation of
  Americans

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Air Pollution
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Air Pollution
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Toxic Exposures

• 13,000-15,000 deaths per day worldwide from
  water-related diseases
• In developing countries, 90-95 of sewage and 70
  of industrial wastes are dumped untreated into
  the local water supply
• 1 in 4 U.S. citizens lives within 4 miles of a
  Superfund site
• Lead and mercury exposure multi-billion dollar
  problems

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Water PollutionBathtubToiletSource of
Drinking Water
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ToxinsMinimata Disease - W Eugene Smith
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Deforestation
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Greenlands Ice Cap Melting 1992
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Greenlands Ice Cap Melting 2002
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Greenlands Ice Cap Melting 2005
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Climate Change Drought
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Famine
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Factory Farms

• 1 polluters of American waterways
• Agriculture accounts for 70 of U.S. antibiotic
  use
• 1 contributor to food-borne, antibiotic-resistant
  infections (CDC)
• Source of MRSA, other resistant bacteria

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Factory Farming
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OverfishingFactory Trawlers
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Dynamite Reef Fishing
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Species Loss Lost Pharmacopoeia

• Drugs from plants and native peoples health
  knowledge
• More than 1/2 of the top 150 prescription drugs
  contain an active compound derived from or
  patterned after natural products-e.g. digoxin,
  vincristine, paralytic agents, etc.
• Of the more than 250,000 known flowering species,
  lt0.5 have been surveyed for medicinal value

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A Cure for Cancer?
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Social Justice Issues

• Maldistribution of wealth
• Overconsumption (affluenza)
• Rise of the corporation
• 53 of the worlds 100 largest economies are
  private corporations 47 are countries
• Minimum wage ? Living wage
• Third World debt crisis
• Human rights abuses

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Maldistribution of Wealth

• U.S Richest 1 of the population owns 50 of
  the countrys wealth poorest 90 own 30
• Widest gap of any industrialized nation

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Maldistribution of Wealth

• Less than 4 of the combined wealth of the 225
  richest individuals in the world would pay for
  ongoing access to basic education, health care,
  adequate food, safe water, and adequate
  sanitation for all humans (UNDP)

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Overconsumption (Affluenza)

• U.S. 6.3 of worlds population
• Owns 50 of the worlds wealth
• U.S. responsible for
• 25 of worlds energy consumption
• 33 of paper use
• 72 of hazardous waste production

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George Orwell

• Some people are more equal than others

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Voltaire

• The comfort of the rich rests upon an abundance
  of the poor

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Primo Levi

• A country is considered the more civilized the
  more the wisdom and efficiency of its laws hinder
  a weak man from becoming too weak or a powerful
  one too powerful.

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Issues

• War and Militarism
• Diversion of economic resources and intellectual
  capital
• Prejudice/hate crimes
• Erosion of civil liberties
• Weapons of mass destruction

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The Military Diversion of Resources Away from
Health Care

• 3 hours world arms spending annual WHO budget
• 1/2 day of world arms spending full childhood
  immunizations for all worlds children
• 3 weeks of world arms spending/yr. primary
  health care for all in poor countries, incl. safe
  water and full immunizations
• War on Terror creating enormous U.S. debt

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War and Peace

• World military budget 1,232 billion in 2006
• 228X what the UN spent on peacekeeping
• US
• Largest military budget, largest arms supplier
• Greatest debtor to UN peacekeeping fund

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• Every gun that is made, every warship launched,
  every rocket fired, signifies in the final sense
  a theft from those who hunger and are not fed,
  those who are cold and not clothed.
• Dwight D. Eisenhower

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• The problem in defense spending is to figure out
  how far you should go without destroying from
  within what you are trying to defend from
  without.
• Dwight D. Eisenhower

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US Anti-Terrorism Spending, 2006
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Kuwaiti Oil Fires Gulf War I
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The Value of the History of Medicine

• Provides context for contemporary practices
• Promotes pride in our field and sense of mission
  to carry on work of our predecessors
• Fosters humility regarding utility of novel
  technologies

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Brigham and Womens Hospital

• Established 1966 through merger of Peter Bent
  Brigham Hospital, Robert Breck Brigham Hospital,
  and Boston Hospital for Women
• 1847 First administration of anesthesia in
  childbirth

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Brigham and Womens HospitalHistory

• 1913 Harvey Cushing named surgeon-in-chief
• Father of modern neurosurgery
• Used X-rays to diagnose brain tumors, electrical
  stimuli to study sensory cortex
• Helped develop Bovie electrocautery
• Discovered Cushings Disease

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Brigham and Womens HospitalHistory

• 1923 Elliott Cutler performs worlds first
  successful heart valve surgery
• 1926 William Murphy, George Whipple, and George
  Minot discover that liver extracts cure
  pernicious anemia
• Awarded Nobel Prize
• 1939 Soma Weiss named physician-in-chief
  co-discoverer of Mallory-Weiss tears

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Brigham and Womens HospitalHistory

• 1949 first use of cortisone for rheumatoid
  arthritis
• 1949 Carl Walter develops worlds first blood
  bank
• 1954 Joseph Murray performs first successful
  human organ (kidney) transplant
• Awarded Nobel Prize

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Brigham and Womens HospitalHistory

• 1962 D/C cardioversion used for first time to
  restore normal heart rhythm in A-fib
• Home of first CCU
• Today one of the largest non-university
  recipients of research funding from NIH
• Contemporary leaders in medicine

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The Role of Literature

• Vicarious experience
• Explore diverse philosophies
• Promotes empathy, critical thinking, flexibility,
  non-dogmatism, self-knowledge
• Encourages creative thinking
• Allows for group discussion/debate

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Why Use Literature

• Encourage appreciation of non-medical literature
• Develop reading, analytical, speaking and writing
  skills
• Promote ethical thinking (narrative ethics)
• Identification with doctor authors (e.g., Keats,
  Chekhov, Maugham, Williams)
• Can be used in a variety of settings

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Homelessness

• Doris Lessing
• An Old Woman and Her Cat
• From the Doris Lessing Reader (New York Knopf,
  1988)

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Race and Access to Care

• Ernest J Gaines
• The Sky is Gray
• in Gray, Marion Secundy, ed. Trials,Tribulations,
  and Celebrations African American Perspectives
  on Health, Illness, Aging and Loss. Yarmouth,
  Maine Intercultural Press, 1992

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Poverty

• Orwell, George. How the Poor Die. In Sonia Orwell
  and Ian Angus, eds. The Collected Essays,
  Journalism and Letter of George Orwell, IV In
  Front of Your Nose, 1945-1950. New York
  Harcourt, Brace and World, Inc pp.223-233.
• Checkhov, Anton. Letter to AF Koni, January 26,
  1891, Letter to AS Survivor, March 9, 1890. In
  Norman Cousins, ed. The Physician in Literature
  Philadelphia WB Saunders, 1982.

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Impediments to Public Health and Social Justice

• Political climate
• Scientific Ignorance
• Pseudoscience
• Damaged educational system
• The corporate media
• All lead to the decline of democracy

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Bush Administration

• Key administrators/committee members/regulators
  former industry representatives and/or lobbyists
• Privatization of public services
• Corporate profit before public good
• Unsound/distorted/suppressed science

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Bush Administration

• Rollbacks of key environmental laws
• Lax enforcement of existing laws
• Huge tax cuts primarily benefit wealthy
• Federal and state government deficits
  astronomical
• Program and funding cuts
• Trade deficit increasing

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Would You Sign a Petition to Ban Dihydrogen
Monoxide?

• 1. It can cause excessive sweating and
  vomiting2. It is a major component in acid
  rain3. It can cause severe burns in its gaseous
  state4. It can kill you if accidentally
  inhaled5. It contributes to erosion6. It
  decreases effectiveness of automobile brakes7.
  It has been found in tumors of terminal cancer
  patients

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Environmental and Geographic Ignorance

• A majority of Americans believe that electricity
  in the U.S. is produced in nonpolluting ways
• 25 knew that majority (70) comes from oil,
  coal and wood
• Percent of US teens unable to locate the
  following on a map
• United States 11
• Pacific Ocean 29
• Japan 58

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Pseudoscientific Beliefs

• Percentage of Americans who believe at least to
  some degree in these phenomena
• 1997 1976
• Astrology 37 17
• UFOs 30 24
• Reincarnation 25 9
• Fortune-Telling 14 4

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Obfuscating Influence of Religion

• Onion Headline

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Greenwash

• Public relations / ad campaigns
• Chevrons People Do Campaign,
  butterflies/refinery
• Grants to a few scientists who challenge
  environmental warnings
• Tobacco ads in 1950s

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Astroturf

• Artificially-created grassroots coalitions
• Corporate front groups
• The American Council on Science and Health
• National Wilderness Institute
• The Foundation for Clean Air Progress

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Corporate-sponsored environmental education
materials (examples)

• Exxons Energy Cube
• -Gasoline is simply solar power hidden in
  decayed matter
• -Offshore drilling creates reefs for fish
• Pacific Lumber Company
• -The Great American Forest is. . . renewable
  forever

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Sponsored Environmental Education Materials
(Examples)

• International Paper
• -Clearcutting promotes growth of trees that
  require full sunlight and allows efficient site
  preparation for the next crop
• American Nuclear Societys Activities with the
  Atoms Family
• Dows Chemipalooza

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Advertising

• Doubt is our product
• Brown and Williamson Tobacco Company Memo, 1960s

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Advertising

• Record 570 billion spent on advertising in 2005
• 11X greater than in 1950
• Half in US
• The average American can recognize over 1,000
  corporate logos, but fewer than 10 plants and
  animals native to his/her locality

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Television

• The average American youth spends 900 hrs/yr in
  school, 1,500 hrs/yr watching TV
• By age 65, the average American will have spent 9
  yrs watching TV
• Contributor to obesity epidemic

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Public Education in Disarray

• U.S. Schools ranked lowest among western nations
• ? funding, infrastructure decaying
• 1/4 of U.S. Schools have no library

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Education in Disarray

• National HS graduation rate 65-70
• College tuition costs rising
• Increasingly marginalizes poor, minorities

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Ignorance vs. Democracy

• Information is the currency of democracy
• Thomas Jefferson

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The Media

• Most media organizations owned by multinational,
  multi-billion dollar corporations that are
  involved in a number of businesses apart from the
  media, such as forestry, pulp and paper mills,
  defense, real estate, oil wells, agriculture,
  steel production, railways, and water and power
  utilities

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Global Warming Controversial?

• Of 928 articles in peer-reviewed scientific
  journals, 0 were in doubt as to the existence or
  cause of global warming
• Of 636 articles in the popular press (NY Times,
  Washington Post, LA Times, WSJ), 53 expressed
  doubt as to the existence (and primary cause) of
  global warming
• Science 20043061686-7
• (Study covers 1993-2003)

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Global Warming

• Causes estimated 160,000 deaths and 5.5 million
  disability-adjusted life years lost per year
• WHO, UN Environment Program

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Lobbying

• 38,000 full-time lobbyists in Washington, DC
• Lobbying groups spent just under 2.5 billion in
  2006 (record)
• All single issue ideological groups combined
  (e.g., pro-choice, anti-abortion, feminist and
  consumer organizations, senior citizens, etc.)
  76.2 million

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The Benefits of Sterility-Causing Chemicals in
the Workplace?

• 12 September 1977
• Dr. Eula Bingham, Assistant Secretary for
  Occupational Safety and Health Regarding
  worker exposure to DBCP. While involuntary
  sterility caused by a manufactured chemical may
  be bad, it is not necessarily so. After all,
  there are many people who are now paying to have
  themselves sterilized to assure they will no
  longer be able to become parents... If possible
  sterility is the main problem, couldnt workers
  who were old enough that they no longer wanted to
  have children accept such positions voluntarily?
  Orsome workers might volunteer for such
  workposts as an alternative to planned surgery
  for a vasectomy or tubal ligation, or as a means
  of getting around religious bans on birth
  control when they want no more children?
• Sincerely,
• Robert K. Phillips, National Peach Council

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The Decline of Democracy

• True democracy demands an informed citizenry
  (education), freedom of the press (media), and
  involvement (will, time, money)

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What you can do

• Explore the history of medicine
• Respect
• Question dogma The least questioned assumptions
  are often the most questionable Paul Broca
• Read great literature
• Patients illnesses are stories
• Take patients perspective
• Develop a public health-oriented perspective in
  care of patients
• Find your passion

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What you can do

• Become active in an organization
• Educate yourself
• Educate your students and your patients
• Use the media
• Volunteer, do pro bono work
• Satisfies your debt to society
• Feeds your soul

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Contemporary Activist Organizations

• Amnesty International, Oxfam
• Partners in Health
• PNHP
• HCWH, NRDC, ED, Greenpeace, Sierra Club, No Dirty
  Gold, PANNA
• Union of Concerned Scientists, Public Citizens
  Health Research Group
• NARAL, Planned Parenthood
• Physicians for Social Responsibility, Physicians
  for Human Rights
• Others

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Anita Roddick

• "If you think you are too small to have an
  impact, try going to bed with a mosquito in your
  tent"

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First they came for the Jewsby Pastor Niemoller

• First they came for the Jews, and I did not
  speak up, for I was not a Jew.
• Then they came for the communists, and I did not
  speak up for I was not a communist.
• Then they came for the trade unionists, and I did
  not speak up, for I was not a trade unionist.
• Then they came for me, and there was no one left
  to speak up for me.

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Contact Information

• Public Health and Social Justice Website
• http//www.phsj.org
• martindonohoe_at_phsj.org