Global Health Equity and the Promise of Social Medicine
Joia Mukherjee
Chief Medical Officer, Partners In Health
This article is excerpted from the commencement address Joia Mukherjee, BS ’85, delivered in May at the 2022 University of Michigan Medical School graduation ceremony. Dr. Mukherjee serves as chief medical officer of Partners in Health, an international medical organization with programs in the United States, Haiti, Rwanda, Lesotho, Malawi, Sierra Leone, Liberia, Peru, Mexico, Russia, Kazakhstan, and the Navajo nation. Her full speech is available on the Center for Global Health Equity YouTube channel.
The pandemic has put medicine and public health on the map like nothing before. The medical science we witnessed was breathtaking. Yet COVID-19 has provided for all of us an object lesson in inequity.
Both in the United States and around the world, the risk of contracting COVID, the access to preventive vaccines and life-saving therapeutics, and the health outcomes of those who fall sick with COVID map the fault lines of our global society.
Social structures are more responsible for life and death than genetics and biology.
Black Americans are 3 times more likely to die of COVID. Only 1% of people in the nation of Burundi have been vaccinated. And the children of day laborers in India have experienced some of the worst malnutrition since the Great Famine.
Biomedical wonders alone have and will continue to fail at ending the pandemic.
Social, political, and economic aspects of COVID—such as pre-existing poverty, food insecurity, high-risk living and working conditions, the politicization of health, and the failure of the market to deliver equitable distribution—are driving the pandemic and all of the consequences the world faces.
It is a challenge to become a doctor at this time. But a medical degree is like an artist’s palette. You get to decide what to paint on the canvas of your life.
You can paint a still life, perfect in its proportions, focused on a single bowl of fruit. You can ignore inequalities and ignore contexts. You can enjoy the practice of medicine and your patients. You can enjoy the world you define. You can treat illness, save lives, and enjoy the privileged position of being a doctor. If that’s what you do, be excellent. We need good doctors.
Another choice would be to paint something large, like Picasso’s Guernica or Faith Ringgold’s American People series. Explore the human condition—the beauty and the pain. Understand and even embrace the complexity. And of course, be excellent.
Practicing Social Medicine
The father of social medicine is Rudolf Virchow, a nineteenth-century German physician. As he famously studied a typhus epidemic, often called “hunger typhus,” he documented the root cause of the epidemic: privation—hunger, squalor, lack of employment. Virchow called for social change to address the epidemic: “The earth brings forth much more food than the people consume. The interests of the human race are not served when, by an absurd concentration of capital and landed property in the hands of single individuals, production is directed into channels that always guide back to the flow of the profits into the same hands.”
Virchow would call for physicians to be “natural lawyers of the poor.” As lawyers, he urged us to collect evidence of the root causes of suffering, to advocate for change with the evidence we have gathered, and in doing so to seek justice.
This might seem overwhelming and hopelessly complex. Social medicine is indeed complex, but it can be boiled down to 3 things:
1. Proximity to patients in caregiving
Regardless of how busy you are, it is well worth your time to know your patients. Patients are people. The art of medicine is rooted in that human connection. The patients we remember best are those with whom we connect most closely. Learn who your patients are, not just the diseases they have.
Your practice will have more meaning, you will enjoy your work more, and you will be a better doctor. Physician burnout so often stems from the disconnection to patients, a disconnect from the humanism that brought us to the field of medicine in the first place. We came to medicine because we like people. Stay connected—it will save you.
2. An analysis of the social conditions in which your patient lives, falls ill, and dies
Proximity to people who are sick and suffering is not always joyful. Their stories, in fact, taught me about the cruelty and violence of the social determinants of health—forces of racism, gender inequality, and poverty that cause and maintain ill health. It is injustice that makes the poor more likely to get sick, suffer, and die. It is not a microbe nor a behavior. To achieve health equity, we must get close to patients so we can assess the social factors that make and keep them sick and work to change those factors.
3. Action to remediate those root causes of suffering
Observing and working in the midst of these material, political, and economic factors that cause health inequality can cause a great deal of despair for all of us. But they can also inspire us to practice social medicine. As the late Paul Farmer wrote, “I have been a partial witness. I am openly on the side of the destitute sick. And I have never sought to represent myself as a neutral party.” Paul rejected the notion of neutrality in the face of oppression, and I hope you will too.
From Doctors to Healers
Center love and caregiving in your practice. And remember, none of us do this alone. Proximity to patients reminds of this human family we are pledged to serve. And doctors are only one small part of the care team that begins with patients themselves and includes their families, their loved ones, their communities, and all the caregivers in their lives.
Proximity to suffering could have broken me. And I could have chosen to focus only on the still life, to just paint the fruit and be done with it. Instead, I found my people—people who love others, who are willing to get close and accompany people on their journey. Everyone on our team—from cleaners to surgeons, from nurses to drivers—is a practitioner of social medicine.
I can share with you countless stories of people on the team who do remarkable things. These are not isolated acts of charity. These are actions that spring from a guiding principle: to analyze the root causes of suffering—marginalization, chronic food insecurity, lack of transportation, lack of a social safety net.
Social structures are more responsible for life and death than genetics and biology. In the US, the first metric for life expectancy is zip code.
The oath we take is to care for the person in front of us to the best of our ability—not the disease, the person. The person as they exist in their family, their community, and the world.
Proximity will help you think of the whole person before you. An analysis of the struggles they face will help you work with them and others to find potential remedies.
In developing your unique approach to medicine it is not the tools you have but how you use them that will transform you from a doctor into a healer.
Joia Mukherjee, BS ’85, is a physician, educator, and health equity advocate. She serves as chief medical officer of Partners in Health (PIH), an international medical organization with programs in the United States, Haiti, Rwanda, Lesotho, Malawi, Sierra Leone, Liberia, Peru, Mexico, Russia, Kazakhstan, and the Navajo nation. In this role, she coordinates and supports PIH’s efforts to provide high-quality, comprehensive health care to the poorest and most vulnerable. Mukherjee is associate professor of Global Health Equity at Brigham and Women’s Hospital and of Global Health and Social Medicine at Harvard Medical School, where she directs the master’s degree program in global health delivery. She is also on the faculty at the University of Global Health Equity in Rwanda. Mukherjee is author of Introduction to Global Health Delivery: Practice, Equity, Human Rights (Oxford University Press).