Literature, Photography, and Social Justice in Medicine

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Literature, Photography, and Social Justice in
Medicine

• Martin Donohoe

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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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Outline

• Background
• History, Literature, Public Health, Social
  Justice
• Teaching Medical Humanities
• Special Topics War, Minimata Disease, Mining
• Conclusions

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• No matter where I might find myself, every sort
  of individual which it is possible to imagine in
  some phase of his development, from the highest
  to the lowest, at some time exhibited himself to
  me.
• - William Carlos Williams

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Luke FildesThe Doctor
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Medicine and Public Health

• Schism between the fields
• Patients vs. Populations
• Witnessed victims vs. statistical victims
• Medical ethics / public health ethics
• Activism

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Causes of Environmental Degradation and Social
Injustice

• Overpopulation
• Pollution
• Deforestation
• Global Warming
• Unsustainable Agricultural/Fishing Practices

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Causes of Environmental Degradation and Social
Injustice

• Overconsumption / Affluenza
• Militarization
• Maldistribution of Wealth
• National and Global Political and Economic
  Institutions
• Exploitation
• Corporate Profiteering

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Causes of Environmental Degradation and Social
Injustice

• International Non-Cooperation/Isolationism
• Poor education
• Media manipulation and inaccurate reporting
• Money in politics
• Citizen apathy

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Consequences of Environmental Degradation and
Social Injustice

• Increased poverty and overcrowding
• Famine
• Global Warming
• Weather extremes
• Species loss
• Human morbidity and mortality
• 40 of worlds yearly deaths linked to water,
  air, and soil pollution
• War
• Malthusian chaos and disaster

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Mahatma Gandhi

• You must be the change you want to see in the
  world

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Important Historical Figures in Public Health and
Social Justice

• Dr. Thomas Hodgkin (abolitionist and opponent of
  British oppression of native populations in South
  Africa and New Zealand)
• Nurse Margaret Sanger (founder of the family
  planning movement in the US)
• Dr. Albert Schweitzer (won Nobel Peace Prize in
  part for developing a missionary hospital for the
  poor in Gabon, Africa)

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Important Historical Figures in Public Health and
Social Justice

• Florence Nightingale (feminist, founder of the
  modern nursing profession, and advocate for
  hygienic hospitals)
• Dr. Salvador Allende (assassinated president of
  Chile and promoter of better living conditions
  for the poor and working classes).
• The quiet and unknown

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Important Literary Figures in Public Health and
Social Justice

• Charles Dickens
• Anton Chekhov
• Upton Sinclair
• George Orwell
• William Carlos Williams

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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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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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Why Use Literature

• Helps to develop reading, analytical, speaking
  and writing skills
• Promotes ethical thinking (narrative ethics)
• Allows identification with doctor authors (e.g.,
  Keats, Chekhov, Maugham, Williams)

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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 Study Literature?

• Why live? Life without literature is reduced to
  penury. It expands you in every way. It
  illuminates what youre doing. It shows you
  possibilities you havent thought of. It enables
  you to live the lives of other peopleIt broadens
  you, it makes you more human. It makes life more
  enjoyable.
• M.H. Abrams

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Nurse Margaret Sanger

• Books have been to me what gold is to the miser,
  what new fields are to the explorer.

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Stigmatization

• John Updike
• From the Journal of a Leper.
• Am J Dermatopathol 19824(2)137-42

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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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Racial Disparities in Health CareAfrican-America
ns

• Equalizing the mortality rates of whites and
  African-Americans would have averted 686,202
  deaths between 1991 and 2000
• Whereas medical advances averted 176,633 deaths
• AJPH 2004942078-2081

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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.
• Eighner, Lars. Phlebitis At the Public Hospital.
  In Travels with Lizbeth. New York St. Martins
  Press, 1993.

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Jacob Riis
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Dorothea Lange
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The State of U.S. Health Care

• 51 million uninsured patients
• 51,000 deaths/year due to lack of health insurance

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Headline from The Onion

• Uninsured Man Hopes His Symptoms Diagnosed This
  Week On House

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The State of U.S. Health Care

• US ranks near the bottom among westernized
  nations in life expectancy and infant mortality,
  and most other health indicators

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Poverty and Inequality in the U.S.

• 22 of children live in poverty
• Food insecurity common
• Gap between rich and poor widening, largest of
  any industrialized nation

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Income Inequality

• Lower life expectancy
• Higher rates of infant and child mortality
• Short height
• Poor self-reported health
• AIDS

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Income Inequality

• Depression
• Mental Illness
• Obesity
• Crime
• Diminished trust in people and institutions (?
  social cohesion)

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Voltaire

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

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Hudson River, 2009
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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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Care for All Equally

• A society should be judged not by how it treats
  its outstanding citizens but by how it treats its
  criminals
• -Fyodor Dostoyevsky

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Meanwhile, Outside the US

• 1 billion people lack access to clean drinking
  water
• 3 billion lack adequate sanitation services
• Hunger kills as many individuals in two days as
  died during the atomic bombing of Hiroshima

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James Nachtwey
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Domestic Violence

• Michael LaCombe
• Playing God
• In LaCombe M, ed. On Being a Doctor.
  Philadelphia American College of Physicians, 1994

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Human Subject Experimentation / Human Rights
Abuses

• Shusaku Endo
• The Sea and Poison
• (New York Taplinger Publishing Co., 1972)

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Conflicting Responsibilities of Physicians

• Pearl S. Buck
• The Enemy
• In Far and Near Stories of Japan, China, and
  America (New York The John Day Company, 1934)

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• War and Peace

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• The role of the physician in the preservation
  and promotion of peace is the most significant
  factor for the attainment of health for all.
• - World Health Organization

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Famous Novels of War and Peace

• War and Peace, Tolstoy
• Red Badge of Courage, Crane
• All Quiet on the Western Front, Remarque
• Johnny Got His Gun, Trumbo
• A Rumor of War, Caputo
• A Canticle for Leibowitz, Miller

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Christopher ColumbusUpon meeting the Arawaks of
the Bahamas

• Theybrought usmanythingsThey willingly
  traded everything they ownedThey do not bear
  armsThey would make fine servantsWith fifty men
  we could subjugate them all and make them do
  whatever we want.

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Josef Stalin

• The death of one man is a tragedy. The death of
  millions is a statistic.

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Horace Odes (III.2.13)

• Dulce et decorum est pro patria mori
• It is sweet and fitting to die for ones country

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"Dulce Et Decorum Est"Wilfred Owen, 1917-18

• In all my dreams, before my helpless sight, He
  plunges at me, guttering, choking, drowning.
• If in some smothering dreams you too could pace
  Behind the wagon that we flung him in, And
  watch the white eyes writhing in his face, His
  hanging face, like a devil's sick of sin

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"Dulce Et Decorum Est"Wilfred Owen

• If you could hear, at every jolt, the blood
  Come gargling from the froth-corrupted lungs,
  Obscene as cancer, bitter as the cud Of vile,
  incurable sores on innocent tongues,- My friend,
  you would not tell with such high zest To
  children ardent for some desperate glory, The
  old Lie Dulce et decorum est Pro patria mori.

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2012 U.S. Federal Discretionary Spending
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Dwight D. Eisenhower

• 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.

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Martin Luther King, Jr.

• Our only hope today lies in our ability to
  recapture the revolutionary spirit and go into a
  sometimes hostile world declaring eternal
  hostility to poverty, racism, and militarism.

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Martin Luther King, Jr.

• Darkness cannot drive out darkness only light
  can do that. Hate cannot drive out hate only
  love can do that.

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• W Eugene Smiths Photos of Minimata Disease

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• More W Eugene Smith Photos

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Sebastiao SalgadoPhotos

• Gold Mining

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Colonial Exploitation

• Cecil Rhodes (Rhodesia, Rhodes Scholarship,
  DeBeers Mining Company)
• We must find new lands from which we can easily
  obtain raw materials and at the same time exploit
  the cheap slave labour that is available from the
  natives of the colonies. The colonies would also
  provide a dumping ground for the surplus goods
  produced in our factories.

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Advice for Students

• Appreciate the privilege of practicing medicine
• Be humble / know your limits
• Contemplate life and death, comfort the grieving
• Take care of yourself
• Cherish your relationships
• Continue your lifelong education
• Strive for justice

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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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Günter Grass

• The first job of a citizen is to keep your mouth
  open.

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African Proverb

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