A Vote for Health
August 15, 2022
By Dr. Angela Sison-Aguilar, Faculty Editor-in-Chief of INSPIRE
“The first task of the doctor is ... political: the struggle against disease must begin with a war against bad government." Man will be totally and definitively cured only if he is first liberated...” (Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception)
Physicians like ourselves would often steer clear of this statement and focus on what we believe we do best, that is, to practice good medicine. However, throughout history, and especially with current national and even local developments, we in the medical profession are challenged to go beyond this comfort zone of traditional professionalism and engage in the very public arena of politics. Why this predicament?
GOVERNMENTS INFLUENCE HEALTH RESOURCE ALLOCATION and SOCIAL DETERMINANTS OF HEALTH
Social determinants affect health outcomes at many levels– individual, national and global. Indeed, many groups in the health professions not only recognize this but incorporate these strategies as well to augment traditional medical interventions [i]. The commitment to public health has never been as important as it is today with the advent of the COVID pandemic [ii]. Without community and national action aided by global support, treating individual patients on one’s lonesome will be an exercise in futility. The health professional striving to achieve a cure for a patient should pay attention to these determinants. The physician should be aware that health disparities produce disappointing outcomes regardless of individual efforts. Lastly, the physician should understand that power structures that influence health and economic policies decide whether the patient lives or dies due to variable access to care. National government policies also influence health outcomes by controlling the health risk exposure of the populace. For example, the intent of Increasing the costs, by imposing higher taxes, on goods such as cigarettes, alcohol, and sugar-containing products–is to limit access to a particular demographic [iii]. In addition, the revenue from these tax measures finances health services targeted to benefit the same demographic [iv]. What brought about these changes in public policy? What influenced the government to craft favorable laws despite the powerful industry lobby? This is the result of collective sectoral action [v]! The cooperation of civil society groups and the leadership of enlightened health advocates provided the effective push to enact this piece of legislation. The impact is not only on individual health but also on societal health as well. The physician participating in this effort not only saved a life but also, collectively, improved national health outcomes.
HEALTH ADVOCACY INFLUENCES PEOPLE TO VOTE FOR GOOD GOVERNANCE
What are we to do with such realizations? How can lessons from such successful campaigns be replicated? Upstream care, as described in the paper by Meili, features the involvement of physicians beyond the active management of the clinical aspects of patient care. Upstream care engages physicians to lift barriers to health improvement. This was previously considered part of the domain of public health. Recently, however, the “traditional” public health approach was criticized as lacking attention towards the “upstream” issues [vi], too preoccupied with “downstream” micro and individual concerns.
More physicians now espouse “upstream” medicine, going beyond the confines of traditional practice, turning their gaze to view the bigger picture. By engaging in health advocacy, they seek to influence not just national policy directly by acting as technical consultants, they also drive the populace to vote for health-responsive politicians. These politicians will in turn form a “good” government, promoting human development. Success in health advocacy will install governments that will enact laws favorable to health, for example, those which will mitigate climate change. Failure in this arena allows the passage of detrimental laws such as the bill known as the Vaporized Nicotine and Non-Nicotine Products Regulation Act, which lowers the minimum age at which individuals can access vape products from 21 years old to 18 [vii].
POLITICAL ENGAGEMENT NECESSARY TO ACHIEVE A HEALTHY SOCIETY
Indeed, there is much to be done in this arena, beyond the traditional scope of our profession as physicians. A recent position paper by the American College of Physicians aims to sway the discourse to promote upstream medicine to further improve health outcomes [viii]. Our national medical societies have since become actively engaged, forming broad coalitions such as the Health Professionals Alliance Against COVID19 (HPAAC) to direct public policy to fight the pandemic [ix]. Another example of collaborative action is the united opposition of the Philippine College of Physicians and other medical societies against the Vape Act. In this day and age, therefore, physicians should be able to redefine their engagement as professionals. Many a treatise on how to incorporate health advocacy in the undergraduate medical curriculum have been published. A redefinition of medical professionalism already includes this new role of promoting societal health and well-being through advocacy [x]. Social accountability and advocacy to ensure equitable health systems are now considered among the required competencies of a medical graduate in progressive medical schools.
Those of us in the academe should support this initiative. Moreover, those of us in the clinics should model this role. In doing so, we uphold the words of Virchow: “Politics is medicine on a larger scale.” It is time to embody this kind of medicine.
[i] Meili, R., & Hewett, N. (2016). Turning Virchow upside down: medicine is politics on a smaller scale. Journal of the Royal Society of Medicine, 109(7), 256-258.
[ii] Peretz, P. J., Islam, N., & Matiz, L. A. (2020). Community health workers and Covid-19—addressing social determinants of health in times of crisis and beyond. New England Journal of Medicine, 383(19), e108.
[iii] Javadinasab, H., Masoudi Asl, I., Vosoogh‐Moghaddam, A., & Najafi, B. (2020). Comparing selected countries using sin tax policy in sustainable health financing: Implications for developing countries. The International journal of health planning and management, 35(1), 68-78.
[iv] Javadinasab, H., Masoudi Asl, I., Vosoogh‐Moghaddam, A., & Najafi, B. (2020). Comparing selected countries using sin tax policy in sustainable health financing: Implications for developing countries. The International journal of health planning and management, 35(1), 68-78.
[v] Hoe, C., Weiger, C., & Cohen, J. E. (2022). Understanding why collective action resulted in greater advances for tobacco control as compared to alcohol control during the Philippines’ Sin Tax Reform: a qualitative study. BMJ open, 12(5), e054060.
[vi] Lantz, P. M. (2019). The medicalization of population health: who will stay upstream?. The Milbank Quarterly, 97(1), 36.
[vii] https://newsinfo.inquirer.net/1635286/bill-allowing-younger-vapers-lapses-into-law
[viii] Daniel, H., Bornstein, S. S., Kane, G. C., & Health and Public Policy Committee of the American College of Physicians*. (2018). Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Annals of internal medicine, 168(8), 577-578.
[ix] http://hpaac.org.ph/
[x] Howell, B. A., Kristal, R. B., Whitmire, L. R., Gentry, M., Rabin, T. L., & Rosenbaum, J. (2019). A systematic review of advocacy curricula in graduate medical education. Journal of general internal medicine, 34(11), 2592-2601.