Above Photo: Supporters of single-payer health care march in Sacramento, Calif., in April. (Rich Pedroncelli / AP)
It’s time to start talking to our patients about climate change and the structural causes of disease. Hurricane Harvey has devastated Texas, leaving many dead, thousands with homes destroyed and billions in damage to infrastructure. Hurricane Irma pummeled the Caribbean and Florida at the same time that Hurricanes Katia and Jose were picking up strength in the Atlantic and threatening Mexico and the Eastern Caribbean. Forest fires are destroying regions of the Pacific Northwest. Meanwhile, in Nigeria, over 100,000 people have been forced to leave their homes because of widespread flooding, and in Southeast Asia over 1,200 have died due to historic flooding, which has left over one-third of Bangladesh under water.
These disasters did not come out of the blue, though. They are just a few examples of what results from an economic system that knows no limits. If the medical community wants to start addressing the systemic causes of illness, instead of just addressing the results that manifest themselves in various degrees of illness for suffering patients, we will have to make addressing the structural aspects of disease central to everyday medical practice.
The System’s Toxic Effect
In medicine, we are often told not to “politicize” health care issues, not to be “too controversial” because “X” residency may not want to accept you, or “Y” employment opportunity may not want to hire you. Frankly, there is no more time for that, especially as we will continue to see more and more patients coming to our offices, clinics and hospitals damaged by this system. To take Texas as an example, in addition to the immediate physical risks associated with widespread flooding and infrastructure destruction, communities will be at risk for a number of health issues, ranging from inadequate access to medical care and prescriptions to an increased risk of mosquito-borne diseases to an increased toll of mental illness from psychological stress.
As usual, poor communities of color will face the largest burden during the most recent disaster, as they have over many years. In the immediate aftermath of Harvey’s destruction, they now will have to sustain the threat of toxic pollution from damaged oil refineries, located near their communities, that were flaring off more than 5.5 million pounds of air pollutants into the atmosphere. (Flaring is done when rapid plant shutdown is required.) These same refineries have leaked chemicals into flood zones. In both methods of pollution, chemicals such as benzene and butadiene, known carcinogens, are released. Unfortunately, these communities, which have suffered from higher rates of respiratory illness and cancer mortality due to excessive environmental pollution from oil refineries, now will be exposed to even greater levels of toxic pollution.
Communities hardest hit by the complications of flooding (such as Port Arthur, Texas) are the same communities that also have suffered from economic devastation over the years as industry has moved abroad to find manufacturing hubs with lax regulations in places like Southeast Asia. These actions have led to high unemployment and all the psychological and physical illness that comes with it. By no coincidence, the residents of Bangladesh—who have suffered from economic exploitation for years, creating vast levels of poverty—now are suffering from the complications of widespread flooding, which will only compound the burden of suffering and illness the population faces.
Understanding what has led us to the situation in Texas and other states requires a more nuanced, systems perspective of evaluation. As Naomi Klein explained, it is important to understand the history that has led us to this point: “There is a moral imperative for informed, caring people to name the real root causes behind this crisis—connecting the dots between climate pollution, systemic racism, underfunding of social services, and overfunding of police.” These connections now must be the focus for medical professionals in their daily practice.
Climate Disaster and Structural Violence: Symptoms From a Capitalist Cancer
What Klein references are what medicine often refers to as the “social determinants of health”—the subtle, upstream factors that continue to drive the devastation of health in communities around the globe. Falling under this umbrella term are forms of “structural violence” that negatively affect the health of communities. In “The New Human Rights Movement,” author and activist Peter Joseph references the 1976 work of Gernot Köhler and Norman Alcock in their defining paper, “An Empirical Table of Structural Violence.” In their work the authors define structural violence by saying, “Whenever persons are harmed, maimed, or killed by poverty and unjust social, political, and economic institutions, systems, or structures, we speak of structural violence, [which] like armed violence can have two effects—it either kills its victims or it harms them in various ways short of killing.” Taking Texas as an example again, whether is it is illnesses communities suffered from before Harvey hit, or the number of illnesses they are at risk for now that it has hit, we see the destructive force of structural violence on the health of communities.
Understanding this definition, we see that companies have committed structural violence on communities for years by actively resisting environmental regulation, disregarding pleas of communities most affected and even ignoring official civil rights complaints to stop polluting around oil refineries. This is no surprise to those who understand how industry operates, as doing so would require funds being diverted from a corporate bottom line, which comes above all else in our current system. As investigative reporting has shown us, companies like ExxonMobil knew about the threats of climate change for years, but purposely misled the public to allow for continued, relentless fossil fuel extraction. They also chose to actively suppress scientific study and social movements that would curtail their bottom lines.
When you question what causes companies like ExxonMobil to act in this way and what leads to these conditions, you start to see that at the core is a neoliberal, capitalist economic market system that is designed for continual growth and profit maximization. As author George Monbiot has noted: “an economic system which depends on perpetual growth on a finite planet is destined to deliver disaster.”
However, the fossil fuel industry is not the only industry to blame for the environmental destruction we are now seeing. It and the military-industrial complex and the factory-farming industry are some of the biggest polluters on earth today. They are operating inside of a system that allows a board of directors and a few wealthy shareholders to make the ultimate decisions about how the companies will operate.
These industries will continue to seek profit maximization at the expense of all else, because it is what the system requires. Continued military expansion, imperialist ventures, fossil fuel extraction and deforestation to make room for cattle grazing show how capitalism operates as a cancer, metastasizing to all aspects of society and every industry. The system commodifies everything it sees, as each industry attempts to continue producing the greatest possible return for shareholders while destroying the earth we inhabit. As we have seen time and time again, the end result of this market system of economics is the spread of illness and the suffering of communities around the world. As physicians, we see the suffering and death of our patients as the ultimate consequence.
What Is Medicine to Do?
Rudolf Virchow, the father of social medicine, once said, “Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”
Unfortunately, all too often discussions around the “social determinants of health” are a secondary concern for medical trainees and physicians. Medicine first will try to alleviate suffering in its immediacy, and this is a great thing. However, if the medical field wants to address the root causes of disease, we must address the social determinants of health. Taking the social determinants of health into account can no longer be something nice to do if there is “extra time.” It must become the focus of medical practice. This will require changing medical education and medical practice.
How would this look? The effort will require an entire restructuring of our for-profit health care system and who becomes a physician within it. As our current system stands, a majority of medical students come from the upper sectors of society. Most of these people already benefit from the capitalist system as it stands and hence are less likely to think about critiquing its negative effects. If the medical system wants students to think about the root causes of disease, it needs to incorporate students from a diversity of socio-economic backgrounds. This would require an entire restructuring of the medical admissions process and even our college admissions process, as students are today being filtered for higher status even before medical school.
As it does with so many other systems, capitalism’s profit motive infiltrates and corrupts all aspects of our society, including medicine. The movement for a single-payer health care system, aimed at bringing the U.S. in line with every other industrialized country that recognizes health care as a fundamental human right, has made great strides, and activists will continue to push for this measure. This hopefully would keep for-profit insurance industries, which are first and foremost beholden to their shareholders, from determining what physicians can deem is best for patient care. This way, the hope would be that well-meaning physicians will not have to practice based on insurance restrictions from an industry that strives to maximize profits regardless of the expense to patients.
Even with single-payer, we will still need to see a change in the general culture of providers. Regardless of the area of medical specialty—whether it’s pediatrics, geriatrics, infectious disease, family medicine or even surgery—you can find the various ways structural violence can and will affect the health of patients if you look hard enough. As physicians who take an oath to treat and prevent disease, we should identify ways to become involved in addressing the “social determinants of health” in our communities. That would mean beginning to explore how the social and structural factors of disease proliferation are intertwined. If medical school administrations cannot or will not provide this education in a sufficient manner, it will be up to progressive-minded students and faculty members to do it themselves until the medical educational system catches up.
In Washington, D.C., for example, we have started a movement of progressive-minded students called Health Care Revolution, which provides educational and community volunteering opportunities for medical students. There are plenty of local community groups and larger national groups (Democratic Socialists of America or Socialist Alternative) operating in communities around the country that seek to address the destructive nature of our current system. In addition to providing volunteer opportunities, these groups provide various educational working groups to allow people from all walks of life to broaden their knowledge. Physicians and medical students joining such groups would allow them to better understand how structural violence can and will affect the health of their patients and practice in a manner that addresses these issues.
Practicing in a way that addresses the social determinants of disease would mean working with our patients to help them institute what author and physician Howard Waitzkin refers to as “unreformist reforms” in his book, “The Second Sickness: Contradictions of Capitalist Health Care.” These are reforms that truly challenge the structures of power in our society. Waitzkin takes many of his suggestions from the success he has seen in the Cuban medical model. This would mean empowering patients to recognize and work toward fundamental societal changes by addressing systems that have been affecting their health.
In the case of Texas, for example, while immediate patient needs of shelter, medicine and emergency care must be met, a physician’s “prescription” may link a patient living in an area polluted with toxic chemicals with community activist organizations working to transition society to a green, sustainable model, so future communities are not plagued with the same issues. This continued effort would make the physician a partner in working toward creating a robust society that prevents disease at its core.
This work may seem daunting, but we cannot allow things to continue on the current course as structural violence will continue to harm our patients. In the words of Desmond Tutu, “If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse, and you say that you are neutral, the mouse will not appreciate your neutrality.” As a medical community, we must not be neutral. We must choose to act in partnership with our patients to create a better society for everyone.