IJCAIP Featured Article

Stories and Society

Using Literature to Teach Medical Students about Public Health and Social Justice

Martin T. Donohoe, MD, FACP

Abstract

This paper presents an argument for enhancing the public health education of medical students through the use of literature, with the goal of creating activist physicians knowledgeable about, and eager to confront, the social, economic, and cultural contributors to illness. The current state of training in ethics and public health will be reviewed, followed by a description of injustices which contribute to poor health. The value of literature to public health education will be described, and specific curricular suggestions offered.

Introduction

This paper presents an argument for enhancing the public health education of medical students through the use of literature, with the goal of creating activist physicians knowledgeable about, and eager to confront, the social, economic, and cultural contributors to illness. The current state of training in ethics and public health will be reviewed, followed by a description of injustices which contribute to poor health. The value of literature to public health education will be described, and specific curricular suggestions offered. While the paper focuses on medical students, its lessons are applicable to all health professionals, practitioners and students alike.

Current Medical School Training in Ethics and Public Health

Despite calls for an increased emphasis on global bioethics,^1,2 contemporary ethics training tends to focus more on fascinating dilemmas involving expensive technologies (e.g., gene therapy, assisted reproduction, cloning, prenatal genetic diagnosis and treatment, and face transplants), while inadequately addressing the psychological, cultural, socioeconomic, occupational, and environmental contributors to the health of individuals and populations.

Social issues and public health are inadequately covered in US medical schools.³ Similarly, human rights, environmental health, women’s reproductive rights, and war and militarization are marginalized.^{4,5,6,7,8,9,10,11,12,13,14,15,16,17,18} Despite the Institute of Medicine’s recommendation that 1/4 to 1/2 of medical students earn the equivalent of a masters in public health, only 10% of students at US public health schools are physicians, down from 60% in the 1960.¹⁹

Barriers to social sciences instruction include: lack of perceived relevance for clinical practice; limited curricular time; lack of qualified instructors; a dearth of commitment from deans and department chairs; inadequate funding; and a paucity of role models. The schism between schools of public health and medical schools that dates back to the early twentieth century -- with medical schools becoming more focused on biochemical mechanisms of disease and drug therapies than on societal issues -- has yet to be healed. Furthermore, the lack of collaboration between nursing schools and medical schools has created an environment not conducive to collaborative learning. This makes post-training collaborative practice, which is critical to solving population-level health problems, more challenging.

Social Injustices and Public Health

This is a time of increasing injustice in health care in the US and worldwide. Today 47 million Americans lack health insurance. Millions more are underinsured, remain in ‘dead-end’ jobs to maintain their health insurance, or go without needed prescriptions because of skyrocketing drug prices. The increasing role played by for-profit corporations in causing and perpetuating worldwide social injustices is mirrored by the pernicious influence of for-profit entities (health maintenance organizations, hospital systems, and pharmaceutical and biotechnology companies) on the American health care system.^{20,21,22,23,24} For-profit health care systems in the US have been widely cited for higher death rates, lower quality of care, and higher administrative costs.²⁵

Patient and physician dissatisfaction with many aspects of our current fragmented health care system is growing.²⁵ Many medical students and residents display increasingly cynical attitudes as their training progresses, and some educators have expressed concern about the adequacy of students’ humanistic and moral development.²⁶ Increasing dissatisfaction, cynicism, and the erosion of professional behaviors among practicing physicians and trainees have been described,²⁷ and interest in primary care among medical students has been declining.²⁸ Tending to physical symptoms often overshadows health professionals' attention to the psychological, economic, social and cultural factors that prompt many outpatient visits and cause as much functional impairment as physical complaints.²⁹ Increasing numbers of physicians from all fields have stopped seeing patients with certain types of insurance, complain of fatigue and burnout, and feel that medicine has lost its soul.²⁷ Some doctors are even leaving the profession. While almost half of US medical schools sponsor student-run health clinics for the indigent,³⁰ the proportion of physicians providing charity care has declined over the last decade.³¹ Meanwhile, most academic medical centers have opened luxury primary care clinics, and concierge care for the wealthy is growing.^32,33

Despite spending a larger proportion of its gross domestic product on health care than any other nation, the US ranks 37th in overall health care system performance.³⁴ In the US, 20-25 percent of its children live in poverty.⁹ Disparities have grown in wealth, access to care, and morbidity and mortality between rich and poor.^9,34 Racial inequalities in processes and outcomes of care persist, some seemingly explainable only by racism or poverty (itself in part a consequence of past and present racism).⁹

Differences between developed and developing nations, in terms of financial, economic, environmental and health-related resources, have further widened and are especially dramatic.^9,10 Over one billion people lack access to clean drinking water, and three billion lack adequate sanitation services. Tens of thousands of children die every day from malnutrition and disease. The worldwide gap between rich and poor doubled over the last 30 years and continues to grow rapidly.^9,10

The United States has failed to sign and/or ratify a number of treaties relevant to human rights, social justice, and public health, such as the Kyoto Protocol on Climate Change; the International Covenant on Economic, Social, and Cultural Rights; the Comprehensive Nuclear Test Ban Treaty; the Convention on the Rights of the Child; the Convention on the Elimination of Discrimination against Women, and the Basel Convention on the Control of Trans-boundary Movements of Hazardous Wastes. Furthermore, our country’s foreign and trade policies have been at odds with the promotion of public health.^{8,9,10,12,13,14,15}

Literature and Public Health

Literature (poems, essays, short stories, and novels) has been integrated into many medical curricula. In general, students have responded enthusiastically to the addition of literature to the medical school curriculum.³⁵

Literature, medicine, and public health share a fundamental concern with the human condition.^{36,37,38,39,40} Through literature, readers can vicariously experience new situations, explore diverse philosophies, and develop empathy with and respect for others whose place in society may be very different from their own. Reading about the experiences of those who suffer the consequences of poverty, racism, stigmatization, and impaired access to health care can help medical students to identify more closely with their patients, whose complex lives they glimpse only during periodic clinic visits. Literature’s instructive and evocative powers can be used to introduce basic principles of social medicine and community health; to facilitate discussion between students regarding the social determinants of illness, the health of populations, and the public health responsibilities of physicians; to increase empathy, understanding, and appreciation of alternative viewpoints; and to encourage students to undertake further studies and/or research in public health, and to publicly work towards solutions to sociomedical problems.^37,38

Curricula covering public health, social justice, and global bioethics might be more interesting and provocative if they incorporated works of literature.^10,37,38

The following are specific examples:

• George Orwell's essay "How the Poor Die"⁴¹ and Anton Chekhov's short story "Ward Six"⁴² offer timeless descriptions of the abysmal conditions which can be found in inadequately-funded public hospitals.

• Doris Lessing's, "An Old Woman and Her Cat,"⁴³ provides a moving fictional entrée into the world of society's dispossessed, through its description of the daily struggles of an aged gypsy and her adopted alley cat trying to cope with life on the streets of London.

• Earnest J. Gaines' short tale, "The Sky is Gray,"⁴⁴ relates the story of a poor, single African-American farm mother trying to obtain dental care for her ill child in a racist Southern farm town.

• Upton Sinclair's novel, The Jungle⁴⁵ describes the harrowing experiences of a poor immigrant family. The novel's revolting descriptions of Chicago's meat packing plants spurred public pressure on Congress to pass the Pure Food and Drug Act of 1906 (the precursor to the US Food and Drug Administration). Henrik Ibsen's play, An Enemy of the People,⁴⁶ portrays a doctor’s battle with city officials to clean up the local water supply.

• William Carlos Williams' short story, "The Paid Nurse,"⁴⁷ describes a community physician's disdain at the inadequate treatment provided to a victim of an industrial accident by a corrupt company doctor.

• Homeless writer Lars Eighner's autobiographical novel, Travels with Lizbeth,⁴⁸ addresses his experience of being (inaccurately) labeled a drug user during a hospital admission for phlebitis. Eighner also graphically describes his street survival tactics, including finding safe shelter, hitchhiking, and dumpster diving.

• Grace Paley's short story, "An Interest in Life,"⁴⁹ profiles a single mother's search for companionship, struggles raising her children, and difficulties navigating through the often-illogical vagaries of the welfare system.

• In William Carlos Williams' brief tale, "The Insane,"⁵⁰ a young pediatrician shares with his physician-father his frustration over the long-term effects on a child's mental health of witnessing violence and of emotional neglect.

• Chekhov's writings on his journey to Sakhalin⁵¹ chronicle the detrimental health consequences of extreme poverty.

• Pastor Niemoller's poem, "First They Came for the Jews,"⁵² powerfully exhorts us to speak out on behalf of the disenfranchised, especially since one day we may join their ranks.

Useful selections for sessions relating to war are Mark Twain’s posthumously-published poem, “The War Prayer,” which portrays the horrors of war and excoriates the hypocrisy of those who pray for victory in battle⁵³ ; Dalton Trumbo’s novel, Johnny Got His Gun,⁵⁴ which describes the harrowing experience of a seriously wounded soldier; Walter Miller’s apocalyptic novel, A Canticle for Leibowitz⁵⁵; Michael Harrison and Christopher Stewart-Clark’s collection of poems entitled Peace and War⁵⁶; works by Premo Levi⁵⁷ and Elie Weisel⁵⁸ describing their Holocaust experiences; and poems by Wilfred Owen and Sigfrid Sasson. Jacobo Timmerman powerfully chronicles his experience of torture in the novel, Prisoner Without a Name, Cell Without a Number.⁵⁹

Literature can be incorporated into the medical school curriculum in myriad ways. Small group discussion sections constitute an ideal venue for the discussion of literary works, which can be taught alongside articles from the medical and public health literature.^37,60 Using short literary selections on ward rounds to help students and residents better comprehend the sociocultural, economic, religious, and personal factors that contribute to health and affect one’s response to illness can improve our insight into patients’ lives, and ideally increase our empathy.

Writing assignments can also be valuable, especially when students are able to share their essays with mentors and colleagues.⁶¹ The medical profession has made important contributions to the literary canon, through the works of Francois Rabelais, Thomas Campion, John Keats, Anton Chekhov, Somerset Maugham, William Carlos Williams, and contemporary doctor-writers like Lewis Thomas, Dannie Abse, and Richard Selzer. While not every physician shares these luminaries’ narrative abilities, all physicians require solid verbal and written communication skills.

Opportunities for students to write about formative experiences in medical school (e.g., critical incident reports) have been shown to be valuable in facilitating personal growth and development.⁶² Some schools require these as part of the medicine clerkship. Others require that students write at least one complete history and physical from the perspective of the patient. Broadening the scope of such writing assignments to include a public health perspective is one way to build on existing pedagogical approaches.

Finally, combining relevant literature with community volunteer work, mentored service-learning projects, or activist-oriented research can broaden students’ educational experiences.^38,63 Interdisciplinary learning involving various health professions students should foster lasting cooperation and collaboration.³⁸

Photography and Public Health Education

Photography also can be a useful adjunct to teaching about social justice. Space precludes a full discussion of this topic, but a few examples might suffice:

• A session on toxic pollution might include W Eugene and Aileen Smith’s photoessay on the health consequences of methylmercury poisoning in Minamata Bay, Japan.⁶⁴

• Dorothea Lange’s poignant pictures of dust bowl migrants evoke the hardscrabble existence of the poor and landless.⁶⁵

• Sebastio Salgado’s dramatic photos of laborers illustrate the consequences of our use of planetary resources, along with providing insight into the dangerous nature of many occupations.⁶⁶

• James Nachtwey’s photographs allow students to enter war zones and visualize the suffering wrought by human conflicts.⁶⁷

The Call to Service

Physicians have an obligation, borne of their privileged status, the public’s investment in their training, and their roles as stewards of the public’s health, to be politically active and ensure that our leaders provide for the sickest among us. Unfortunately, while physicians recognize the importance of community participation, political involvement, and collective advocacy,⁶⁸ they have lower adjusted voting rates than the general population.⁶⁹ When doctors lobby Congress, they focus on issues such as reimbursement and funding for medical research, rather than access to care for the uninsured, tobacco control, women’s rights, violence prevention, and other social justice issues.⁷⁰ Physician-legislators are rare today compared with past centuries.⁷¹

Physicians also have a responsibility to oppose, individually and collectively, those forces which contribute to the spread of poverty, over-consumption, the maldistribution of wealth, the economic, political, legal, and educational marginalization of women, environmental degradation, racism, human rights abuses, and militarization and war. This is especially true now, when fewer scientists hold positions of authority than in times past, and when scientific truths have been deliberately obfuscated by the well-funded and sophisticated public relations and lobbying campaigns of those with a vested interest in profiting from the provision of a basic human right like health care.

Doctors as Social Justice Advocates

There are many noteworthy examples of physician-advocates, about whom medical students know too little. For example, pathologist Rudolph Virchow, best known for establishing the cell doctrine in pathology and elucidating the pathophysiology of thrombosis, pulmonary embolism, leukocytosis, and leukemia, made equally valuable contributions to social medicine.⁷² Virchow wrote, “Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.” ⁷³ He argued that many diseases result from the unequal distribution of civilization’s advantages. He felt that physicians were the natural advocates of the poor, and opined, “If medicine is really to accomplish its great task, it must intervene in political and social life.”⁷⁴ Virchow served as a legislator and founded a journal entitled Medical Reform. He spoke out for public provision of medical care for the indigent, prohibition of child labor, universal education, and free and unlimited democracy. He instituted programs for improving water and sewage systems, stricter food inspection, and improved education and training of health professionals.⁷²

Other health professionals have led inspiring lives of social activism, including 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 (who won the Nobel Peace Prize in part for developing a missionary hospital for the poor in Gabon, Africa); Florence Nightingale (feminist, founder of the modern nursing profession, and advocate for hygienic hospitals); and Dr. Salvador Allende (assassinated president of Chile and promoter of better living conditions for the poor and working classes). Many individuals labor today, often anonymously, in support of the disenfranchised. Others work through well-known physician-activist organizations, such as Physicians for Human Rights, Doctors without Borders, Physicians for a National Health Plan, Physicians for Social Responsibility, and the Doctors Reform Society. Increased attention during medical training to social justice and to history and literature relevant to physician activism may encourage students to become more involved in activism throughout their careers.

Conclusions

The importance of economic, social, and cultural contributors to population health demands that physicians’ training in these areas be enhanced. One pedagogical approach to augmenting such public health training and to encourage physician activism is through the use of literature. The vicarious experiences afforded by reading the powerful stories of great authors can ideally enhance trainees’ attentiveness to their patients’ needs and motivate physicians to become more active in addressing the health care needs of their communities and the world.

Acknowledgments:

The author thanks Karen Adams, MD, FACOG for editorial support.

Martin T. Donohoe, MD, FACP,
Adjunct Associate Professor, School of Community Health
Portland State University
Chief Science Advisor, Campaign for Safe Food
Member Board of Advisors Oregon Physicians for Social Responsibility
Senior Physician, Internal Medicine
Kaiser Sunnyside Medical Centre
Website: http://phsj.org/

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