by D. Frederick Sparks
The classic version of the Hippocratic Oath states that a physician should keep the sick from “harm and injustice”. A modern version of the oath used in many medical schools declares that physicians should remember that they remain members of society, “with special obligations to all fellow human beings, those sound of mind and body as well as the infirm.”
For some physicians, living out the promises of their oaths manifests itself in using their platform and medical expertise to highlight issues of social justice and social inequality, and in particular, the degree to which social inequities impact health outcomes.
Physicians and Criminal Justice Reform
In 2013, the venerable television show Sesame Street introduced the character Alex, a young boy who reluctantly reveals to his friends that his father is incarcerated. Alex serves as a voice for the increasing number of children with at least one incarcerated parent.
The introduction of this character served as an unlikely catalyst for a group of physicians to make a call to action for doctors to address the impact of mass incarceration on health outcomes. In an article published in the Annals of Internal Medicine, the group of doctors noted that incarceration is a Social Determinant of Health (SDOH), and that SDOHs such as incarceration, poverty, and housing and educational disparities shape patients’ health and access to care. The article also notes that while incarceration is a finite experience, a history of incarceration may lead to lasting negative health outcomes, as the formerly incarcerated experience higher rates of homelessness, lower rates of employment, and permanent disqualification from many anti-poverty and health assistance programs all of which are factors associated with poorer health. Importantly, the health consequences affect not only to the incarcerated person, but also the family members including children.
The organization Physicians for Criminal Justice Reform (PfCJR) was launched in May 11, 2015, co-founded by Dr. Edjah Nduom, a neurosurgeon (all similarities to a former presidential candidate end there) currently serving as a Staff Clinician in the Surgical Neurology Branch at the National Institutes of Health, and Dr. Nzinga Harrison, a psychiatrist who is the Chief Medical Officer for Anka Behavioral Health, Inc., a private, non-profit mental health system. According to Dr. Nduom, the organization was struck by the myriad of ways in which negative interactions with the criminal justice system lead to detrimental health consequences. They believe that changing the interactions between the criminal justice system and targeted communities will lead to improved health outcomes. PfCJR has organized its advocacy efforts around three core issues:
- Decriminalization of mental health and addictive disorders, noting that individuals with severe mental illness are three times more likely to be in a jail or prison than in a mental health facility and 40 percent of individuals with a severe mental illness will have spent some time in their lives in either jail, prison, or community corrections.
- Reform of the juvenile justice system to identify and divert at risk adolescents, as research suggests that as many as 70 percent of youth in the juvenile justice system have a diagnosable mental health disorder. And youth housed in adult jails are 36 times more likely to commit suicide than are youth housed in juvenile detention facilities. Also, youth under the age of 18 represented 21 percent of all substantiated victims of inmate-on-inmate sexual violence in jails in 2005, and 13 percent in 2006 – despite the fact that only 1 percent of inmates are juveniles, a
- Provision of adequate access to physical and psychiatric health care for current inmates. Prison inmates have a higher incidence of chronic and infectious diseases, such as AIDS and hepatitis C, and mental illness than that of the general population.
Since its founding, PfCJR has established several partnerships to help physicians use their specific medical expertise to further the cause of one of the most significant civil rights issues of our time. In a new partnership with the Campaign for Youth Justice, they are using their knowledge of the difference between the brain biology of juveniles and adults to support the need to #raisetheage of criminal responsibility in states that treat juvenile offenders as adults. The group has also been traveling the country, presenting for the American Medical Association Young Physicians Section, the Student National Medical Association, the American Psychiatric Association and the National Physicians Alliance. “All physicians naturally want to find ways to improve the health of our communities,” says Dr Nduom. “When we let our colleagues know the many ways that healthcare intersects with the criminal justice system, many physicians find that they are already working on our core issues, but did not realize that their work was actually part of a social justice movement.”
Targeted Services to Underserved Populations
In addition to specific political and civic advocacy, physicians contribute to the push for social justice through targeted services to underserved populations. The French founded group Doctors Without Borders is one of the most well-known groups providing medical services and supplies to disadvantaged populations globally. More locally, In Los Angeles and other cities, many doctors are practicing ‘street medicine‘ , in which healthcare providers go to where homeless patients are, rather than waiting for them to come to offices and emergency rooms. Other physicians have specifically targeted under-served populations within their research and clinical practice. Dr. Sande Okelo, Division Chief of Pediatric Pulmonology at Mattel Children’s Hospital UCLA, focuses on developing tools and strategies to improve asthma care, particularly for poor, minority and under-served children who are most at risk for poor asthma care and poor outcomes.
Public Trust and the Medical Profession
A study completed in 2014 found that, in the United States, the level of public trust in physicians as a group ranked near the bottom of trust levels in 29 industrialized countries (though, paradoxically, Americans reported higher satisfaction with their individual health care provider than with providers as a group). The level of mistrust, particularly when it comes to participating in medical research studies, is more pronounced among African-Americans. The author of the 2014 report stated that a key to improving this perception may be physicians and professional societies like the AMA taking “more visible stands on issues broadly affecting people’s health.” The work that some physicians are doing around criminal justice reform, access for underserved populations, and other social justice issues may help not only in providing a more comprehensive level of care that considers various societal inputs to health outcomes, but may also serve to enhance public trust in the profession.