Hershey, Pennsylvania (Winter 2017)
A fourteen-year-old girl, large with child, presented to her community health center in northern Uganda. Blood was rushing down her legs, and she was doubled over in pain. Immediately, the medical officer called the ambulance. Tears ran down the girl’s face – she never wanted this baby. She had asked the nurses to help her miscarry months ago, after her uncle raped her. Ashamed, the health workers declined to help. The law allowed abortion, but only under “certain” yet unspecified circumstances, and they feared retribution and prison.
It took two hours for the vehicle to make it out over the bumpy, unpaved road, and another hour to get back to the main hospital. The girl looked faint; she was rushed to the operating room for an emergent C-section. It was too late, and the young woman and her infant died.
Unfortunately, many versions of this sad story arose during my month-long stay in northern Uganda, where a woman dies in childbirth every ninety minutes. I spent the month of January in the small town of Gulu, enrolled in a social medicine course named SocMed with twenty-five other healthcare students from around the world. Students from Uganda, Zimbabwe, Rwanda, Lebanon, and the United States arrived with a multitude of experiences and perspectives to share, with a shared desire to learn more about social justice and achieving health equity for all. Together we dove into the history of colonialism in Africa and of conflict-ridden Uganda, unpacked theories of global health and development, and explored what it meant to become an advocate and build a social movement. We learned to look at patients such as this fourteen- year- old girl and ask –why? Why were these women dying so unjustly? How did they end up in such structurally violent situations, with poor access to healthcare, no social capital, and ineffective policies? We visited villages and learned about cultural practices tied to health, shadowed bike-mounted village health workers as they visited their communities, assessed hospitalized patients for their structural vulnerabilities, and much more.
So what is social medicine, the concept at the heart of this SocMed course? Social medicine is a body of knowledge and practices that incorporate the social, political, economic, and cultural determinants of health into the practice of medicine. As a course, we approached the subject with a “geographically broad and historically deep” lens as exemplified by Paul Farmer, immersing ourselves in the history of Eastern Africa and examining the evolution of our world’s neoliberal policies and economics. We defined various approaches to global health including charity, development, and social justice and listed their positive aspects and shortcomings. We discussed the ethical quandaries that global health interventions posed, from unintended consequences and bio power to lingering medical colonialism and exploitation.
To convert learning into practice, we completed multiple group activities and designed one larger-scope project. Within multinational teams, we identified larger health issues within Uganda and devised upstream interventions to address the root causes, and completed an advocacy action before the conclusion of the course. For our group’s project, we developed a multimedia plea to Parliament to amend Article 22 of the Ugandan Constitution, which currently legalizes abortion but under nonspecific circumstances, making most healthcare workers unwilling to provide any services at all. As a result, one in ten pregnant women die in Uganda, and 26% of these women die from unsafe abortion practices performed outside of health facilities. Our advocacy campaign demanded clarification of the law, and the legalization of abortion in circumstances of maternal health compromise, incest, rape, fetal abnormality, or maternal HIV.
Beyond the completion of mere coursework, these past four weeks deconstructed my past experiences and training in global health and development and rebuilt my perspectives and ideals on a foundation of social justice. The course directly confronted my past internal conflicts with foreign aid and development ideology, which I viewed often as apologetic stopgap solutions failing to fix intrinsic problems, often poorly informed for each specific context. Previously, within the context of my Masters in Public Health, I felt well versed in strategizing to build cost effective, sustainable interventions with key stakeholder buy in, after an appropriate data collection and root cause analysis: albeit important skills, they were rooted in neoliberal concepts and ultimately were downstream approaches. In this course, I deepened my historical understanding of the economic and political forces at play in the oppression of African countries, forces that I knew were present yet never fully understood how they were the root cause of most of the systemic injustices we face now. This small exposure has fueled my interest to learn more about this history and investigate contemporary approaches to fix these underlying processes at play, both within my home country of the United States and abroad.
Listening to my colleagues and instructors engage in deep dialogue about these historical scars and the legacy they leave behind, I was urged to both despair and rejoice. These soul-crushing issues seem so large and impossible to change with such powerful forces at play within political and economic spheres. Yet there was still an element of hope as we listened to each other’s perspectives, ideas for change, past success stories, and shared frustrations with failing systems.
In medical and in public health school curricula, we learn about the determinants of health and the biopsychosocial approach. We learn to identify issues that may affect our patients, to ask the tough questions and refer to a social worker as needed. Yet what is lacking in this teaching is the ability to get to the heart of the issues, the underlying reasons these problems exist, the policies, markets, and environments that expose our patients to such structural violence. And even if we do investigate and uncover these issues, it is far out of the scope of our training to know how to influence greater change and advocate beyond the case presentation of a single patient.
Social medicine has the flexibility to widen and narrow the focus, from deep underlying systemic flaws to the illness narrative of a single patient. Every medical student should graduate with some exposure of its principles, and its potential impact on both their individual patients and the injustices of this world. Understanding the political, economic, and social context from the scale of a community to a country will only become more relevant to our practice in the upcoming years. Healthcare has become a commodity instead of a right in most societies, and the widening income gap puts many services well out of the majority of patients’ reach. Physicians have a role to step up as advocates, to realize that true patient care will demand raising their voices outside of the clinics. We should not feel trapped in silence by the unjust death of a raped fourteen- year-old girl in childbirth. Doctors must demand change in national health policies, healthcare funding, and increase in access to medications and services.
As a future physician, I am grateful for this early exposure to social medicine and know that it will play a large role in the care for my future patients. A fundamental outlook of health in the context of history, policy, economics, and social values should be at the heart of all medical education, and students should be armed with the voice and skills to advocate against injustices rooted within these contexts. I take my future Hippocratic Oath to heart, in that “I will prevent disease whenever I can but I will always look for a path to cure all diseases,” a sentiment that reiterates our responsibility to ensure health for our society beyond our narrow clinical practice.
ALEXANDRA ADAMS is a third year medical student at the Penn State College of Medicine, where she helps manage the student-run free clinic and serves as a class officer. Lexy intends to pursue a career in general surgery as an Army officer in the Health Professions Scholarship Program. She completed her Masters in Public Health and Bachelor of Arts degrees at Yale University.