Social medicine in the 21st century

This week PLoS Medicine publishes a unique collection of articles devoted to social and cultural aspects of medicine, featuring some of the leaders in the field, such as Paul Farmer, David Satcher, Arthur Kleinman, Leon Eisenberg, Nancy Scheper-Hughes, and Rafael Campo. The entire collection will be freely available and linked to from the PLoS Medicine homepage: http://www.plosmedicine.org/


Study Finds Different Patterns of Street-Based Drug Use Among White and African American Men

Among men who live on the streets and inject heroin, there are important differences between African American men and white men in their patterns of drug use, risk of health problems, and strategies for survival, according to a unique study published in PLoS Medicine.

Over the course of six years, researchers Philippe Bourgois and colleagues (University of California San Francisco and Cornell University) observed about 70 men living in the shooting encampments of the San Francisco Bay Area. At times the researchers lived with the men as part of their study, interviewing them, and recording their daily lives with photographs. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men.

The health status of homeless heroin users is extremely poor, and they are highly stigmatized, including by health professionals. Physicians, nurses, and social workers often treat these men in emergency rooms and free clinics and regularly find the interactions frustrating and confrontational.

The researchers wanted to see whether there were differences between the white and African American heroin users. Knowledge of such differences would help the health community to provide more tailored, culturally appropriate interventions.

The study found that the white men were more likely to supplement heroin use with inexpensive fortified wine, while the African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime; these men tended to consider themselves as destitute outcasts. African American men had earlier, more negative contact with law enforcement but maintained long-term ties with their extended families; these men tended to consider themselves as professional outlaws.

The white men persevered less in attempting to find a vein for injection, and so were more likely to inject heroin directly under the skin--this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most income through offering services such as washing car windows or through petty crime. .

The researchers hope that their study results will help health professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients. "Understanding of different ethnic populations of drug injectors," they say, "may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care."

Citation: Bourgois P, Martinez A, Kral A, Edlin BR, Schonberg J, et al. (2006) Reinterpreting ethnic patterns among white and African American men who inject heroin: A social science of medicine approach. PLoS Med 3(10): e452.

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CONTACT:

Philippe Bourgois

Professor, Department of Anthropology, History and Social Medicine
University of California, San Francisco
Philippe.bourgois@ucsf.edu

OR:

Janet Basu

jbasu@pubaff.ucsf.edu
+1 415-476-2557


Hierarchy of health in farm workers in the US

Subtle racism and anti-immigrant practices determine the poor working conditions, living conditions, and health of migrant workers in the farming industry in the Western United States, finds a new research study published in this special issue of PLoS Medicine.

The paper, by Seth M. Holmes from UCSF, reports findings gathered over 15 months as the author traveled with a group of indigenous Triqui Mexican farm workers as they moved between Mexico and the Western USA. Using qualitative research methods, the author observed and interviewed migrant workers and health care professionals.

He found that farm working and housing conditions are organized according to ethnicity and immigration status, and that the hierarchy that develops determines health disparities, with undocumented indigenous Mexicans having the worst health. In Holmes' interviews with all the participants it became clear that the hierarchy has become accepted and that each group is somehow understood to "deserve its place in the hierarchy". He found that structural inequalities and subtle forms of racism cause health professionals to be less aware of these social determinants of suffering and often lead them to blame their migrant patients for their sicknesses.

The author calls the relationship between US society and migrant workers a "dishonest" one that must be acknowledged and changed and while recognizing that "medical education must be broadened to reflect the multifaceted etiology of disease", concludes that "Medical professionals have the calling and the authority to work toward this change."

Citation: Holmes SM (2006) An ethnographic study of the social context of migrant health in the United States. PLoS Med 3(10): e448.

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CONTACT:

Dr. Seth M. Holmes

UCSF School of Medicine
323 Lincoln Way
San Francisco, CA 94122 United States of America
+1 415-846-3067

seth.holmes@ucsf.edu


Combating vCJD in the US and the UK

A study of the differences between the approaches adopted by the authorities in the US and UK to combat variant Creutzfeldt-Jakob disease (vCJD) has found that scientific evidence is not the only the factor determining how governments react to health crises. The research was conducted by Dr Maya Ponte of the University of California, San Francisco.

When vCJD, also described as being the human form of 'mad cow disease'(BSE), appeared in the late 1990s, the authorities in many countries became concerned that the disease agent (or 'prion') responsible might contaminate blood supplies for transfusion, thus leading to a major epidemic. In both the US and the UK, procedures were put in place to reduce the chance of this happening. The officials concerned attempted to do so in a fully 'scientific' manner, but faced the problem that there was a lack of reliable information about how the disease was transmitted. In the end, the two countries decided on very different changes to their respective regulations on blood donation. Both countries chose to prevent certain people from donating blood. In the UK, however, the decision was made to remove white blood cells from donated blood, while the US decided that such a step was not merited by the evidence.

Dr Ponte wanted to understand more clearly why the UK and US ended up with different policies: what role was played by science, and how important were other factors? She searched for all relevant official government documents from the US and UK, as well as scientific papers. She also interviewed people who knew about vCJD management in the two Countries; for example, members of government agencies and advisory committees.

Although these documents and interviews suggested that policy making was rooted in the limited scientific evidence then available, many non-scientific factors were also important. Policy makers felt guilty about a previous experience in which people had become infected with HIV/AIDS through contaminated blood and were concerned about repeating this experience. And, in the UK, the possibility of blood contamination was seen as a much more urgent problem than in the US, because BSE and vCJD were found there first and there were far more cases. In addition, the scientific evidence that UK advisors relied on in making their decision to remove white blood cells from donated blood came to them ahead of publication through a social network of regulators and scientists. In the US, a social network made up of different scientists and regulators emphasized contradictory evidence.

Dr Ponte's study has shown that historical and social factors such as previous experience, sense of urgency, public pressure, and the relative importance of different scientific networks influenced the responses to vCJD. The same is likely to be the case in future outbreaks of new diseases.

Citation: Ponte ML (2006) Insights into the management of emerging infections: Regulating variant Creutzfeldt-Jakob disease transfusion risk in the UK and the US. PLoS Med 3(10): e342.

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VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030342

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CONTACT:

Maya Ponte

University of California San Francisco
Anthropology, History, and Social Medicine
1446 Rhode Island St.
San Francisco, CA 94107 United States of America
+ 1 415-401-8210
maya.ponte@ucsf.edu


Indigenous Health and Socioeconomic Status in India

The approximately 90 million people in India who are classed as 'scheduled tribes' have been shown - by an international group of researchers - to face higher risks of sickness and death than the rest of the country's 1.1 billion population.

The scheduled tribes are examples of indigenous (or aboriginal) peoples. In other words, they are the descendants of people who occupied their land in ancient times, but they now live as minorities, while the majority population are the descendants of people who arrived considerably later. The scheduled tribes are often marginalised from the rest of society. It was already thought likely that their health was worse than that of other Indians, but evidence on what accounts for this difference was lacking until now.

The researchers analysed figures collected in the 1998-1999 Indian National Family Health Survey. When this survey was conducted, it was noted whether people were considered to be members of scheduled tribes. The researchers also knew from the survey about the standard of living of the families, their death rates, and whether they drank alcohol or smoked or chewed tobacco. They found that, even allowing for factors such as standard of living, an indigenous person was still 20% more likely to die than a non-indigenous person. Standard of living, however, did account for much of the substantial differences in indigenous and non-indigenous health.

The researchers went on further to show that, within the indigenous communities, those who had the highest income had lower death rates than the poorer members of those communities. The existence of this so-called 'socioeconomic gradient' shows that - while the social marginalisation of the scheduled tribes does put them at a disadvantage - if their standard of living could be improved, there would be major benefits for their health and welfare. This demonstration that the dominant factors are social and economic should help discourage the view, still sometimes expressed, that the poor health of indigenous people is mainly due to genetic reasons.

Citation: Subramanian SV, Smith GD, Subramanyam M (2006) Indigenous health and socioeconomic status in India. PLoS Med 3(10) e421.

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CONTACT:

S V Subramanian

Harvard School of Public Health
Department of Society, Human Development and Health
677 Huntington Avenue
KRESGE 7th floor
Boston, MA 02115 United States of America
+1 617-432-6299
+1 617-432-3123 (fax)
svsubram@hsph.harvard.edu


Surgeon General Urges Public to Role to Play in Reducing Health Disparities

If we had eliminated ethnic disparities in health in the last century, there would have been 83,500 fewer deaths of African Americans in the year 2000 alone, says David Satcher, the 16th US Surgeon General, in a compelling essay in PLoS Medicine.

"In seeking solutions to the problem of ethnic disparities," he says, "we all must be proactive as advocates for change." Dr Satcher outlines his vision for how everyone can play a crucial role in reducing disparities by, among other things, advocating for universal access to health care, ensuring greater representation of minority populations in the health professions, creating non-violent and exercise friendly neighborhoods, and supporting research on why health disparities persist.

"We all have roles to play in the elimination of ethnic disparities in health," says Dr Satcher. "We must all care enough; we must know enough; we must do enough; and we must persist in our efforts until health disparities are eliminated in this country."

Citation: Satcher D (2006) Ethnic disparities in health: The public's role in working for equality. PLoS Med 3(10): e405.

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CONTACT:

David Satcher

Morehouse School of Medicine
720 Westview Drive SW
Atlanta, GA 30310 United States of America
+1 404 756-8803
+1 404 756-8974 (fax)
bmoore@msm.edu


Hurricane Katrina Showed Link Between Social Inequality and Health

Who lived or died in the wake of Hurricane Katrina was "more a reflection of available housing and transportation options, not biologic risk factors," say a group of social medicine scholars in their essay on why social medicine still matters.

Although nature triggers environmental disasters, say Timothy Holtz (Emory University), Leon Eisenberg (Harvard University), Scott Stonington (UCSF) and Seth Holmes (UCSF), there is nothing "natural"about the way in which certain people are more likely to die. "All disasters are shaped by the context and hierarchy of human social organization," they say.

The authors argue that the link between social inequality and ill health is seen in nearly every field of medicine and public health, not just in disaster situations, but in the stark ethnic differences in health and in the way in which patients who need the most health care often receive the least (the "inverse care law").

"If we want to fulfill our role as medical professionals," say Holtz and colleagues, "we cannot confine our alleviation of suffering to patient biology. Our bedside manner should be extended to an informed 'community-side manner' that considers all the social contributing factors to human health."

Citation: Holtz TH, Holmes S, Stonington S, Eisenberg L (2006) Health is still social: Contemporary examples in the age of the genome. PLoS Med 3(10): e419.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030419

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CONTACT:

Leon Eisenberg

Harvard Medical School
Social Medicine
641 Huntington Avenue
Boston, MA 02115-6019 United States of America
+1 617-432-1710
+1 617-432-2565 (fax)
Leon_Eisenberg@HMS.Harvard.edu


Is It Ethical for Patients with Kidney Disease to Purchase Kidneys from the World's Poor?

One controversial, and almost universally illegal, approach to tackling the shortage of kidneys for transplantation is for a patient with kidney disease to buy a kidney from a living donor who is usually in a developing country. But is the buying and selling of organs ethical? A provocative debate in PLoS Medicine considers both sides of the issue.

Tarif Bakdash, a pediatric neurologist and Assistant Professor of Bioethicis at Damascus University, Syria, argues that "poor people should have the right to exercise their autonomy by selling their organs."

The argument that we should protect the poor from being exploited by banning them from selling their organs is a myth, says Dr Bakdash. "The poor are always exploited from the day they are born," he says, "and in all avenues of life. The only thing of value left for some of them is their bodies." Dr Bakdash believes that the sale of organs should be legalized and regulated.

But Nancy Scheper-Hughes, Professor of Medical Anthropology at the University of California, Berkeley, and Director of Organs Watch, argues that "dividing the world into organ buyers and sellers is a medical, social, and moral tragedy."

Research done by Professor Schepher Hughes and colleagues found that among hundreds of kidney sellers in Moldova, Romania, Turkey, the Philippines, and Brazil, many suffer post-operatively from chronic pain, social isolation, stigma, and severe psychological problems. "While many individuals have benefited from the ability to get the organs they need through illegal circuits," she says, "the violence associated with kidney selling gives reason to pause."

Citation: Bakdash T, Scheper-Hughes N (2006) Is it ethical for patients with renal disease to purchase kidneys from the world's poor? PLoS Med 3(10): e349.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030349

PRESS-ONLY PREVIEW OF THE ARTICLE: http://www.plos.org/press/plme-03-10-bakdash.pdf

CONTACTS:

Tarif Bakdash

University of Toronto
The Joint Center for Bioethics
88 College Street
Toronto, ON M5G 1L4 Canada
trsbakdash@yahoo.com

Nancy Scheper-Hughes

University of California, Berkeley
Medical Anthropology and Director of Organs
Berkeley, CA United States of America
nsh@berkeley.edu


Structural Violence is Impeding HIV Prevention and Care

"Structural violence", the social arrangements that put individuals and populations in harm's way, has a profoundly negative impact upon people living with HIV, say Paul Farmer and his colleagues from the renowned health NGO Partners in Health (PIH).

Professor Farmer and colleagues analyze how structural violence operates in the context of HIV prevention and treatment in Rwanda and the US, and show that "structural interventions" can have a powerful effect on the lives of those with HIV.

Researchers in Baltimore in the early 1990s, for example, showed that African Americans with HIV were receiving worse medical care: they were less likely than whites to be given HIV medications. Once these ethnic disparities had been documented, clinicians and researchers were able to adress them by, for example, implementing improvements in community-based care conceived to make AIDS care more convenient and socially acceptable for patients, removing economic barriers at the point of care, paying for transportation costs, and other incentives.

PIH is now working in two rural districts of Rwanda where an estimated 60 percent of inhabitants are refugees, returning exiles, or recent settlers. When PIH arrived in May 2005, not a single physician was present to serve 350,000 people. "AIDS has recently worsened this situation," say Farmer and colleagues "and is a leading cause of young adult death." In its first six months of operation, PIH screened more than 31,000 people for HIV, and began a program to reduce mother-to-child HIV transmission.

These examples, say the authors, show that "it is possible to decrease the extent to which social inequalities become embodied as health disparities."

Citation: Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) Structural violence and clinical medicine. PLoS Med 3(10): e449.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030449

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CONTACTS:

Paul Farmer

Harvard Medical School
Department of Social Medicine
641 Huntington Avenue
Boston, MA 02115 United States of America
paul_farmer@hms.harvard.edu

###

Other Highlights from the Social Medicine Collection:

* Dorothy Porter examines the history of social medicine and asks where it is heading.

* Arthur Kleinman and Peter Benson discuss "anthropology in the clinic": how culture matters in the interactions between doctors and patients.

* Rafael Campo gives a personal view of why patients' stories are so important.

* Scott Stonington and Pinit Ratanakul explore end of life care in Thailand, arguing that Western bioethics cannot always solve ethical dilemmas in non-Western contexts.

* Rajesh Gupta makes the case for medical students to learn about global health policy.

* Colin Butler and Sharon Friel urge the health community to strongly re-engage with environmental and ecological issues.

Citation: Porter D (2006) How did social medicine evolve and where is it heading? PLoS Med 3(10): e399.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030399

PRESS-ONLY PREVIEW OF THE ARTICLE: http://www.plos.org/press/plme-03-10-porter.pdf

CONTACTS:

Dorothy Porter

University of California San Francisco
Anthropology, History and Social Medicine
3333 California St.
Ste. 485
San Francisco, CA 94143-0850 United States of America
+1 415-476-8826
porterd@dahsm.ucsf.edu

Citation: Kleinman A, Benson P (2006) Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Med 3(10): e294.

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CONTACTS:

Arthur Kleinman

Harvard Medical School, Harvard University
Department of Anthropology and Departmnet of Pyschiatry
William James Hall
Cambridge, MA 02138 United States of America
+1 617-495-3846
kleinman@wjh.harvard.edu

Citation: Campo R (2006) "Anecdotal evidence": Why narratives matter to medical practice. PLoS Med 3(10): e423.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030423

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CONTACTS:

Rafael Campo

Beth Israel Deaconess Medical Center
Division of General Internal Medicine
330 Brookline Avenue
Boston, MA 02215 United States of America
+1 617.667.9699
+1 617.667.9620 (fax)
rcampo@bidmc.harvard.edu

Citation: Stonington S, Ratanakul P (2006) Is there a global bioethics? End-of-life in Thailand and the case for local difference. PLoS Med 3(10): e439.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030439

PRESS-ONLY PREVIEW OF THE ARTICLE: http://www.plos.org/press/plme-03-10-stonington.pdf

CONTACTS:

Scott Stonington

University of California, San Francisco
Medicine; Anthropology, History and Social Medicine
3333 California Street, Suite 485
San Francisco, CA 94122 United States of America
+1-650-743-7117
scott.stonington@ucsf.edu

Citation: Gupta R (2006) Why should medical students care about health policy? PLoS Med 3(10): e199.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030199

PRESS-ONLY PREVIEW OF THE ARTICLE: http://www.plos.org/press/plme-03-10-gupta.pdf CONTACTS:
Rajesh Gupta
Stanford University
School of Medicine
Stanford, CA 94025 United States of America
+1 650.799.0790
rgupta1@stanford.edu

Citation: Butler CD, Friel S (2006) Time to regenerate: Ecosystems and health promotion. PLoS Med 3(10): e394.

PLEASE ADD THE LINK TO THE PUBLISHED ARTICLE IN ONLINE VERSIONS OF YOUR REPORT: http://dx.doi.org/10.1371/journal.pmed.0030394

PRESS-ONLY PREVIEW OF THE ARTICLE: http://www.plos.org/press/plme-03-10-butler.pdf CONTACTS:
Colin Butler
Deakin University
School of Health and Social Development
221 Burwood Hwy
Melbourne, Vic 3125 Australia
+61-3-63811675
+61-3-9244 46086 (fax)
colin.butler@deakin.edu.au

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