Emory SocialMedCourse13

Social Responsibilityof the Health Professional: 

Social Responsibility of the Health Professional

Slide2: 

What role do we, as physicians, play in addressing the social routes of ill health? Duties beyond the clinic/hospital setting “Political action” vs. “social responsibility”

Goals of engaging in socially responsible health promotion: 

Goals of engaging in socially responsible health promotion Impact existing structural, political, economic, etc. forces that underlie poor health Examples Improve access to care for all Alter physical (highways) & cultural (gender roles) infrastructure Conflict prevention & resolution

Two models of “social responsibility”: 

Two models of “social responsibility” REFORMIST Operate within existing power structures TRANSFORMATIVE Challenge existing power structures

Applications: 

Applications Injury prevention (pediatric) * leading cause of mortality (< 25yrs.) Conflict/war prevention * a dominant contributor to mortality worldwide

Injury prevention: 

Injury prevention  Injury is the leading cause of death and disability for children in the US.  Injury accounts for 12,500 deaths (1/2 of child mortality) per year. For each death there are 20 admissions and 200 cases of morbidity

Injury Prevention: 

Injury Prevention Historically: In the past 20 years, pediatric motor vehicle collision injuries have decreased, while pediatric firearm mortality has increased 40% since 1986. Worldwide: The US ranks 21st-24th among 25 industrialized nations for pediatric injury death. [Unintentional firearm injuries are 9x greater than 24 other industrialized nations.] Risk groups:  Boys,  Low birthweight,  Young, uneducated, multiparous mothers not seeking prenatal care,

Slide8: 

     Firearms Falls MVCs    

Injury Prevention: 

Injury Prevention Legislation,  $$,  availability are more effective than education Community partnerships – e.g. smoke detector canvassing Advocacy (evidence-based) – e.g. poison prevention law (1970), Seattle bike helmets, pool fences

Conflict prevention: 

Conflict prevention

Objectives: 

Objectives To present the different paths physicians have taken to address conflict To compare and discuss these roles in light of ethics, humanitarianism, and human rights

Overview: 

Overview During the conflict Humanitarian, neutral, … and silent (ICRC) Rebellious humanitarianism (MSF) War at home (local physicians) Military physicians Observers and advocates

Overview (cont.): 

Overview (cont.) Post-conflict Providing care Documentation Preventing conflict Advocacy & education Promoting stability

Overview (cont.): 

Overview (cont.) Other issues Alternatives to war  Embargoes War for health? Discussion Ethical dilemmas What role would you play?

During Conflict: Medical Impartiality: 

During Conflict: Medical Impartiality Historical records suggest preferential treatment of ‘friends’ over ‘enemies’ during times of conflict Nurses (F. Nightingale and D. Dix) Started the impartiality movement  treating all equally Roots of medical personnel seen as neutral  not taking part in war

During Conflict: Medical Impartiality (cont.): 

During Conflict: Medical Impartiality (cont.) Henri Dunant – founder of Red Cross (ICRC) 1959 observed Battle of Solferino Organized medical services for Austrian and French wounded First Geneva Convention (1864) formed ICRC – signatories to document agreed to impartiality and neutrality Won First Nobel Prize

During Conflict: Medical Impartiality (cont.): 

During Conflict: Medical Impartiality (cont.) Humanitarian vs. Human Rights Law Humanitarian  indicates behavior for parties during war in relation to people at mercy of the conflict Human rights  the rights of individuals to treatment by or protection from government abuses

During Conflict: Medical Impartiality (cont.): 

During Conflict: Medical Impartiality (cont.) Four Geneva Protocols (1864-1949) plus 2 provisions – Humanitarian law Humane treatment for all persons (not hostile) Medical workers not punished for providing care to all (Medical Neutrality) Access to those in need  Article 3: impartial humanitarian bodies allowed to offer services (ICRC) Impartiality of treatment Medical workers bear light arms Attacks on civilians prohibited

During Conflict: International Committee for the Red Cross: 

During Conflict: International Committee for the Red Cross ICRC fundamental principles: humanity, impartiality,neutrality, independence Independence – in the face of power makes humanitarian presence acceptable to warring parties Independence – abstain from all communications and comments on its mission

During Conflict: Rebellious Humanitarianism: 

During Conflict: Rebellious Humanitarianism Medecins Sans Frontieres (MSF) Late 1960s genocide against Biafrans in Nigeria “The ethics of the Red Cross are solely valid in a world where violence against mankind comes only from eruptions, floods, crickets or rats. And not men.” In 1971 formed MSF.

During Conflict: Rebellious Humanitarianism (MSF): 

During Conflict: Rebellious Humanitarianism (MSF) Go where needed, not where allowed Bear witness to human rights violations and blocked relief “Temoignage”– commitment to testimony, open advocacy and outright denunciation when working with endangered populations Violating neutrality – MSF President Brauman called for military intervention in Bosnia 1999 Nobel Peace Prize – pioneering humanitarian assistance throughout the world

During conflict: War at home: 

During conflict: War at home As a physician, when your homeland is attacked what do you do? Bosnian doctors – combat or noncombat? Serbians – Serbian president was a psychiatrist Iraq – organizations facilitate treatment

During the conflict: Military physicians: 

During the conflict: Military physicians Historical mandate of military physicians required prioritization of health for ‘friends’ before ‘enemies’ Hippocrates – provided succor to ‘friends’ only in time of war Special forces medical training may jeopardize medical neutrality

During the conflict: Military physicians (cont.): 

During the conflict: Military physicians (cont.) Conflicts for military physicians (Sidel) Prioritization of military personnel Emphasis on fighting strength Combatant / non-combatant US obligation versus international obligation Conflict based on medical ethics Captain Yolanda Huet-Vaughn (US Army Medical Service Reserve)

During conflict: Documentation: 

During conflict: Documentation Monitoring humanitarian and military efforts for impact on health Sphere project (1997) – Humanitarian standards Richard Garfield - combines qualitative perspective of community health promotion and the quantitative skills of epidemiology to assess morbidity and mortality changes among civilian groups in humanitarian crises around the world.

During conflict: Deadly band-aids: 

During conflict: Deadly band-aids “MSF questions the appropriateness of humanitarian medical and psychological assistance when, in the presence of internationally mandated protection forces, the fundamental rights of people are being denied.”

POST-CONFLICT: 

POST-CONFLICT

Post-Conflict: Providing care: 

Post-Conflict: Providing care Post-conflict settings present altered epidemiological profiles Malnutrition and communicable diseases Diarrheal diseases are a leading cause of child mortality Interrupted care leads to excess mortality (e.g. TB & HIV)

Post-conflict: Providing care: 

Post-conflict: Providing care “Refugee camps are the emergency departments of international public health. Over the past few years, the emergency departments have filled and patients are lining up for admission.”

Post conflict: Mental health: 

Post conflict: Mental health Unique mental health needs for survivors Minimize mortality while promoting human dignity Challenge to “illness in person” model Recovery through social rebuilding No evidence for catharsis from testifying for South Africans

Post conflict: Documentation: 

Post conflict: Documentation Documentation allows for monitoring outcomes of conflict such as mass graves, use of banned weapons, use of rape as a military tactic. These findings can be used to bring offenders to international criminal court and mobilize support for survivors.

Post-conflict: Documentation: 

Post-conflict: Documentation Documentation is also helpful for survivors to find resolution for missing and killed family members.

Preventing Conflict: 

Preventing Conflict

Preventing conflict: 

Preventing conflict “Public health is based on the assumption that this is not a fatalistic world, that risks can be reduced by identifying and developing interventions that lower the risk and implementing those interventions. The risk of arms, violence, conflict, can be measured and reduced by conscious deliberate acts. The crucial step is to recognize this risk as a public health problem.” – Bill Foege.

Preventing conflict: Advocacy: 

Preventing conflict: Advocacy Work by Sidel, Levy and others illustrates effect of medical advocacy on policy. PSR (1961) documented the effect of nuclear arms proliferation on health and the environment Won 1985 Nobel Prize with International Physicians for the Prevention of Nuclear War

Preventing conflict: Promoting stability: 

Preventing conflict: Promoting stability Social justice Amount of money spent on arms in importing countries in conflict as well as exporting countries (such as the US) could be diverted to programs promoting stability such as education, economic development, health, etc. Economic development International lending policies (IMF, World Bank) engender instability and conflict.

Other issues: 

Other issues

Alternative to war: Embargoes: 

Alternative to war: Embargoes Background – US (28 countries); UN (9) 34% ‘success’ rate ?? Types of embargoes Trade Arms Communications International criminal prosecution

Alternative to war: Embargoes: 

Alternative to war: Embargoes Iraq – Rise in under 5 mortality (56-131), 300,000 excess child deaths Cuba – Neuropathy, GBS, lye poisoning Haiti – Rise in maternal mortality, social destabilization Yugoslavia – TB, decreased immunization Alternative – positive sanctions

War for health? : 

War for health? Military force accompanying health initiatives Military force to improve conditions for health “Waging war is evil, but sometimes it is the much lesser evil.” – Sheri Fink

Discussion: 

Discussion Ethics of health professionals in conflict Comparing physicians activities related to conflict E.g the Red Cross model vs. the MSF model Military intervention to improve health?