Social Responsibility of the Health Professional

1. Social Responsibilityof the Health Professional

2. 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”

3. 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

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

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

6. 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

7. 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,

8. Avg. deaths/yr 1249 301 1509 US (rate) 13.7 4.3 16.4 Georgia (rate) 17.8 5.7 21.8 Excess deaths/yr 286 98 378 Firearms Falls MVCs

9. 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

10. Conflict prevention

11. 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

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

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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

24. 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)

25. 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.

26. 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.”

27. POST-CONFLICT

28. 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)

29. 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.”

30. 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

31. 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.

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

33. Preventing Conflict

34. 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.

35. 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

36. 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.

37. Other issues

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

39. 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

40. 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

42. 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?