ABSTRACT
In the wake of the September 11th attacks, the editors of the New England Journal of Medicine (NEJM) and The Lancet published editorials offering conflicting advice to members of the medical community about how we should respond to the attacks. While the NEJM editors suggest that the ideal response is to provide patients affected by the attacks with excellent medical care, Richard Horton, editor of the Lancet, argues that physicians must also respond to the broader social and political contexts that give rise to terrorism, war, and other forms of violence. It is commonly held that physician responsibility includes our obligation to both treat disease and to strive to prevent it from developing in the first place. In the following paper, I will argue that insofar as physicians, medical students, and other health professionals are capable of influencing the social and political determinants of health, we ought to advocate on behalf of our patients in the social and political sphere.
On October 11, 2001, the editors of the New England Journal of Medicine published an editorial that discusses how physicians ought to respond to the 9/11 attacks. The editors implore physicians to focus on medical and mental health care for victims and their families. They state that “We are physicians, not politicians,” and argue that physicians must therefore fulfill their designated role and act on “the core value of our profession: healing” [1]. As healers, they explain, physicians must treat injured patients, continue with medical research, and ensure that the medical community is prepared for future terrorist attacks. They argue that the essence of the appropriate reaction is not to react directly to the terrorism, but rather to “seize this moment to look beyond our responses to terrorist attacks” and to be excellent clinicians [1].
In reply to the NEJM article, Richard Horton published an editorial in The Lancet which posits that physicians and health professionals ought to respond more broadly to the attack than simply to care for patients well. Rather, explains Horton, it is appropriate and desirable for physicians to act in the political sphere for the betterment of patients:
To argue that medicine's interests should concentrate on healing…is too narrow a view of the doctor's role. Those working in the health professions are as concerned with prevention as with healing. So doctors must involve themselves with the conditions that foster violence…It is a trivial truth to say that doctors are not politicians. But medicine and its institutions cannot escape politics. To reduce the burden of harm caused by violence, doctors must address how the political determines the clinical [2].
The disagreement between the editors of the NEJM and Horton is fundamentally about the appropriate scope of physicians' professional obligation. In order to determine whether we ought to be involved in a particular issue that relates to our patients, health service professionals need a metric that delimits our obligations. In a recent article, Gruen and colleagues provide such a metric. Their model offers two tests to measure whether issues that affect patients fall within the domain of physicians' responsibilities. When confronted with such issues, a physician must first discern how directly a particular issue relates to the health of her patients. Second, she must discern what is the “feasibility and efficacy of physician involvement” [3].
Since September 11th, it has been obvious that war is an issue that directly affects the health of patients in the United States. In addition to causing the deaths of those murdered on September 11th, the attacks have lead to the mobilization of a quarter million American troops to fight wars in Afghanistan and Iraq. These campaigns have already led to greater than ten times the serviceperson mortality of Operation Desert Storm. More than 3,000 Americans soldiers have died and 20,000 have been seriously wounded. If patterns from previous wars hold, these quarter-million Iraq and Afghanistan war veterans who return to the U.S. without severe physical wounds will still have high long term morbidity: this population of veterans will suffer above baseline rates of a host of conditions, including depression, alcoholism, and Post Traumatic Stress Disorder (PTSD). War's capacity to decrease the health of Americans includes not only our soldiers, but also their spouses. Recent research shows that female partners of combat veterans from the current wars have elevated levels of PTSD and related psychiatric burdens [4]. Thus, those of us currently in training will be treating patients who are dealing with the health effects of the current wars for our entire careers.
War satisfies Gruen's first test: War directly impinges upon the well-being of many of our patients. Gruen's second test requires that we ask: How feasible is it for physicians and other health professionals to intervene and how effective can we expect to be? In order to understand the various roles that physicians might play with respect to war, Yusuf and colleagues have suggested that we employ the metaphor of disease:
Try thinking of war as a complex disease process that attacks the global “group organism” humankind. Think of this disease as having risk factors that can be prevented from developing (primordial prevention) or modified (primary prevention) and whose effects we must treat (secondary prevention); and think of war as a condition which, once it has done its damage, leaves us with the tasks of healing and rehabilitation (tertiary prevention) [5].
Yusuf holds that health professionals have a role to play at every level of prevention. Physicians should not just undertake tertiary prevention, which would be the rehabilitation of those patients physically and psychologically wounded by war. Physicians should also engage in secondary prevention—designing interventions to short-circuit extant wars and contribute to the establishment of peace. We should engage in primary prevention—working to prevent conflicts from evolving into active wars. And we should pursue primordial prevention—preventing the “risk factors” that make war an option for parties, such as the proliferation of armaments [5]. To agree with Yusuf is not to be naïve about the ease with which we might succeed in these earlier levels of prevention, but rather to be committed, at a minimum, to pursuing those prevention techniques that have a proven record.
In this edition of Context, I discuss successful interventions through which physicians have advanced prevention, and I provide guidance to health care professionals interested in engaging in such interventions with Palestinians and Israelis [6]. Indeed, there is substantial evidence that physicians have been effective in the implementation of interventions that advanced each of these levels of prevention. Physicians involved in the campaign to ban landmines advanced primordial prevention by providing epidemiological data on landmine-related morbidity and mortality and by lobbying for wide-acceptance of the ban [7]. The International Physicians for the Prevention of Nuclear War were effective in their primary prevention efforts, as they educated Reagan and Gorbachev about the health consequences of turning the Cold War into an active nuclear conflict [8]. And vaccination cease-fires have been an effective means of secondary prevention, halting active wars in order to provide childhood immunizations [9]. Since physicians can feasibly undertake effective political and social interventions in order to reduce the burden of war and violence, physician participation in such interventions meets Gruen's second test.
More than a quarter century ago, the World Health Organization (WHO) formally recognized that health professionals must play a greater role with regard to war than simply treating its victims. In 1981, the WHO resolved: “The role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all" [10]. Since this declaration, the WHO has supported a number of programs which have facilitated the participation of health professionals in interventions that advance early prevention of war. Still—as evidenced by the disparate responses of the NEJM and the Lancet—there is not wide consensus in the medical community that physicians should be involved in matters of war and peace. Yet, such involvement is not going above and beyond the call of duty, but rather meeting widely held expectations. According to Gruen and colleagues, “most members of western societies...expect physicians to do everything within their means to reduce each patient's burden of illness” [3]. It is within our means to reduce our patients' burden of illness by pursuing interventions that advance the early prevention of war and, therefore, it is our professional obligation to do so.
Contrary to what the editors of the NEJM might indicate, appropriate physician responses to health burden associated with terrorism and war extends beyond the clinic. Providing the best medical therapies is necessary, but it is not a sufficient effort on behalf of our patients. Health professionals in disciplines that more fully recognize the superiority of early prevention over late treatment (treatment of patients already injured by war) ought to take a key role in leading the medical establishment toward recognizing that all health professionals have a role to play in early prevention. Just like diabetes or heart disease, early prevention of war leads to better outcomes than treating this social illness after it has become fulminant. While it is impossible for any health professional to respond to all of the threats to health that war and violence entail, each health professional ought to “choose some activities that are consistent with his or her expertise, interests, and situation” in order to benefit our patients [3]. By acting collectively to oppose those social factors such as war that undermine our patients' health, health professionals can be more effective advocates for our patients.
[1] The Editors. (2001). September 11, 2001. NEJM, 345(15), 1126-1127.
[2] Horton, R. (2001). Violence and medicine: the necessary politics of public health. The Lancet, 358(9292), 1472-1473.
[3] Gruen, R. L., Pearson, S. D., & Brennan, T. A. (2004). Physician-Citizens-Public Roles and Professional Obligations. JAMA, 291(1), 94-98.
[4] Manguno-Mire, G., Sautter, F., Lyons, J., Myers, L., Perry, D., Sherman, M., et al. (2007). Psychological Distress and Burden Among Female Partners of Combat Veterans With PTSD. J Nerv Ment Dis, 195(2), 144-151.
[5] Yusuf, S., Anand, S., & MacQueen, G. (1998a). Can medicine prevent war? Imaginative thinking shows that it might. BMJ, 317(7174), 1669-1670.
[6] Morse, M. (2007). Medical Students As Peace-Builders: Health as a Bridge for Peace between Palestinians and Israelis. Context, Spring, vol. 1.
[7] Meddings, D. R. (2002). The value of credible data from under-resourced areas. Med Confl Surviv, 18(4), 380-388.
[9] MacQueen, G., & Santa-Barbara, J. (2000). Peace building through health initiatives. BMJ, 321(7256), 293-296.
Michael Morse is a second year medical student at Harvard Medical School.
I thank Ken Sharpe for introducing me to ethical inquiry and Jake Berger for helping me to communicate clearly. I thank my wife Miriam for her support and inspiration.
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