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All Doctors Should Be Social Activists

By Sofia Weiss Goitiandia and Izzy Edwards

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Citation

Goitiandia S, Edwards I. All doctors should be social activists. HPHR. 2021;30.

All Doctors Should Be Social Activists

Abstract

This evidenced-based opinion piece addresses the roles of a doctor beyond the immediate remit of their clinics, theatres, and laboratories. It argues that medics have the opportunity to not only act in the best interests of their individual patients, but also to the benefit of the wider populations, and society, that they serve. Though this may not always appear the most evident part of a physician’s job description, we contend that the role of the doctor as social activist is one rooted in history, and – as research evinces – is profoundly necessary in light of the most pressing challenges facing medicine, and humanity, in the 21st century.

BJ Miller, a well-known US palliative care physician, said in his TED talk that “healthcare was designed with diseases, not people at its centre. Which is to say, of course, it was badly designed.” The radical expansion of our knowledge of and ability to manage disease has meant that modern medicine, and the doctors who are trained for it, can have  tunnel-like vision into pathologies and their potential cures. Even those medical students and doctors who have a tendency, through nature or good teaching, to see patients as whole biopsychosocial entities might be missing something evident in the first line of the Declaration of Geneva: “I solemnly pledge to dedicate my life to the service of humanity. As doctors, we are called to work not only to the benefit of our own patients, but of all human-kind.

 

To us, this means that exercising ‘social responsibility’ forms an integral part of the job of a doctor. In practice this looks like doctors being educated about the population-level determinants of health and illness, and realising that their practice as clinicians should address these as central to disease rather than an afterthought. Yet these are the big, wicked problems of our society; how can an individual even start to make an impact?

 

A good example of where this is critically important comes in the form of our prejudices as humans. However good and fair we are, all of us have unconscious, preconceived biases about people we encounter day to  . These include biases around race, class, gender, sexual orientation, gender identity, disability and many others. For doctors, these can affect how much we listen to and believe a patient, and how we choose to talk to them.

 

Marginalised groups are known to seek healthcare later, less frequently and with more trepidation than the general population. With recent research in the LGBT+ community showing that a quarter (24 per cent) of patient-facing staff have heard colleagues make negative remarks about lesbian, gay or bi people, and 20% have heard similar disparaging remarks about trans people, it is not hard to see why. Even if we do not realise we are being insensitive, as a profession all too often we are driving away those who most need our help. 

 

One action we can all take to tackle this issue is to start small and reflect upon our own biases: acknowledge that they are there; question our assumptions about our patients and alter our behaviour accordingly; educate ourselves about social justice issues, and seek to understand why our biases might impact good healthcare delivery for our patients. We can discuss this with others, listen to people from marginalised groups and consider what we can do to make ourselves more accessible and empathetic. It is not a large change, but it could revolutionise trust and care. 

 

On a larger scale, the need for social responsibility in medicine is exemplified by the climate crisis, which presents us with a bizarre conflict in the profession. The Lancet has named the climate crisis the single “greatest threat to public health in the 21st century”. Yet, many healthcare systems are major emitters of CO2 and other greenhouse gases, as well as huge users of single use plastics. We know that deaths due to drought, food shortage and extreme weather are happening because of climate breakdown, and we are becoming increasingly aware that our profession is contributing. So, what on earth are we supposed to do? Where does our social responsibility lie here?

 

We cannot stop treating our patients, and we cannot abandon humanity to suffer climate and ecological collapse. However, we can use social activism to push for a system that allows us to treat both. A system that recognises that the increase in children presenting to us with asthma is linked to pollution, and that fuel poverty in winter and extreme heat in summer bring people to our emergency departments. Doctors are already taking to the streets to protest the level of inaction on this issue, some taking part in marches, sit ins, citizens assemblies, giving educational talks and taking part in Non-Violent Direct Action (NVDA) to stand up for their patients’ right to a liveable planet. These individuals care deeply about their patients, and are – in line with the Declaration of Geneva – standing up to protect humanity from an existential threat, that no medicine or surgery can solve. They speak of it not as a choice, but as their duty as clinicians. We all can, and should, follow their lead and get involved in advocating for policies to respond to climate change, including those that aim to make modern medicine a more environmentally respectful endeavour. These are policies that would save lives. 

 

From the suffragists, to the Civil Rights movement, to individuals like Harvey Milk and wider campaigns for LGBT rights, the world is a more equal and inclusive place for the successes of social activism. Medicine too has benefitted thus far: we can think of John Snow and his influence on cholera, of Paul Farmer and his dedication to increasing equity in global health, or of Judith Mackay, and her achievements in tobacco-control advocacy. Their sense of social responsibility and subsequent activism were not peripheral to their medical practice, but integral parts of it.

Social activism is a valid, legal and proportionate treatment for the social problems that lead to the diseases that doctors the world over are seeing in their consulting rooms. Yet doctors who take stands on population-level issues are often ignored, or viewed as overly political. Let us be clear: there is nothing political about challenging a system that itself contributes to homelessness, cancers, depression, and a plethora of other diseases. There is nothing political about wanting the best for humanity.

Challenges facing the healthcare system in Yemen during the COVID-19 pandemic

Yemen suffers from a real health crisis due to the fragile health system and the continuing outbreaks of infectious diseases, such as diphtheria, dengue fever, and currently COVID-19 (1).

Healthcare facilities in Yemen are not ready as they lack the capacity to avoid the threat of a COVID-19 pandemic. Most health care units do not have enough intensive care units, beds, and isolation rooms. Also, there are huge deficits in essential medical supplies, testing capabilities, and protective personnel equipment. They also do not have enough plans to deal with the spread of COVID-19 (2).

There are many problems that the healthcare system faces, including:

  • More than 50% of people do not have access to safe drinking water
  • More than two million children and pregnant women suffer from acute malnutrition
  • Lack of technical personnel necessary for field investigation or active monitoring
  • Lack of a national strategy for the workforce to recruit epidemiologists
  • The national laboratory system is primitive and depends on a small number of central laboratories such as the National Central Laboratory of Public Health in Sana’a and its four branches in the governorates of Aden, Taiz, Hadramawt, and Al-Hudaydah. The weaknesses of the laboratory system are not only limited to the number of national laboratories but also due to the lack of PCRs and reagents to detect COVID-19 cases, there are only six polymerase chain reaction (PCR) machines available in Yemen (11). Moreover, there are only 500 available ventilators in the whole country (12).
  • Masks, gloves, and sanitizers are not sufficient to be spread among the citizens.


The spread of the COVID-19 pandemic will make matters worse and cause pressure on health facilities. Therefore, measures must be taken as soon as possible.

The fragmented authority system and armed gangs are among the most important difficulties facing the implementation of the International Health Regulations and related legislation and policies during disease outbreaks. The Yemeni government was unable to prepare sufficient sites for isolation at entry points into the country and was unable to meet the standards of the International Health Regulations in response to epidemics. Yemeni entry points have little to no technical capacity or systems in place to effectively deal with suspected infected travelers. Moreover, Yemen has a long coastal border, which regularly receives thousands of migrants and refugees from the Horn of Africa. And how the country can implement public health measures in response to migration movements across its porous borders and ports is not yet clear.

Yemen suffers from conflict, mismanagement, and a lack of a good relationship between the government and citizens. The government and the international community must act now more decisively (9).
Basic healthcare facilities are unapproachable to about 16.4 million individuals. The infectious and communicable diseases services are available only in 43% of health facilities, and maternal immunization coverage and immunization plans for children services are available in only 35% of functional health facilities.

The health care system in Yemen is not capable of tackling the outbreak like other middle and high-income countries. The massive insufficiency of the very basic and essential medicines, as well as health kits, makes the healthcare status of Yemen vulnerable and rely on the World Health Organization and other private and humanitarian organizations’ aid (10).

Health system functions, such as access to health care personnel and their capacity, are less than 40% (2). The vast majority (93.9%) believed that the healthcare system in Yemen does not have the resources and capabilities to face and manage a COVID-19 outbreak (3).
82.4% of healthcare workers rated the general alert level of their healthcare facilities as very bad or weak. They also mentioned the unavailability of equipment such as mechanical ventilation devices, diagnostic devices, ICU rooms and beds, and isolation rooms (3). Health care workers have assessed the general level of preparedness of the country’s health care facilities as very weak, poor, ill-equipped, and lacking the most basic facilities and resources to deal with a pandemic (2). Approximately 80% of the population in Yemen has achieved the largest humanitarian crisis worldwide. Therefore, it needs all kinds of humanitarian, medical and food aid (2).

Unstable daily life and armed conflicts have led to high rates of deaths, injuries, food shortages, and have exemplified the low efficiency of the health care system in Yemen. Few and insecure shelters, immigration, lack of medicine and food, lack of sanitary water, non-existing vaccines, and almost zero hygiene policies make the scene much worse. Also, the irregularity of giving salaries to the healthcare workers by the government and the attacks on healthcare workers because of the civil war contribute to worsening the condition even more.
Based on the most recent estimates of the Ministry of Public Health and Population in Yemen, COVID-19 may expand and infect 90% of Yemenis, and this is expected to cause even more deaths than air strikes (5).

Although recorded cases do not seem to be high, the alert of crisis is poor and healthcare workers may be at a high risk of catching the Corona Virus. This does not indicate that Yemen is ready for any upcoming pandemics in the future.

The health care system in Yemen is comprised of four level of facilities; health units, health centers, district or governorate hospitals, and referral hospitals. There are approximately 4207 public health facilities including 243 hospitals.The poverty and ongoing civil war since 2015 has affected the country very badly. Many healthcare related infrastures are in jeopardy making hygiene and sanitation systems even poorer(13)

 

The role of international initiatives and institutions in aiding Yemen during the COVID-19 epidemic

According to the World Health Organization (WHO), only 51% of health facilities are functioning well due to the war (4). Therefore, we appeal to international organizations to intervene urgently.

Yemen relies heavily on the support of health organizations, especially when it comes to the health system. There are 39 health cluster partners providing support to healthcare services as of December 2019 (2).

International Initiative on COVID-19 in Yemen (IICY), is a collaborative partnership of multinational companies and the United Nations— assists in relieving the healthcare crisis by providing more funding to support actions already taken by the World Health Organization. IICY’s founding members include: The Hayel Saeed Anam Foundation, Tetra Pak, Unilever, the United Nations, the Yemen Private Sector Cluster, and the Federation of Yemen Chambers of Commerce and Industry.

IICY’s donated 43-tonnes of laboratory supplies; ventilators, test kits, PCR machines, and personal protective equipment, to fight COVID-19 in Yemen. Shipment delivery was managed by the World Food Programme to avoid delays (2).

To control and eliminate this pandemic is to end the war in cooperation with international organizations and end the land, sea, and air blockade imposed by the coalition (5).

War and the weak health system are the main reasons for low testing capacity in terms of logistics and locations, as there are only three sites in the entire country (5). This causes the virus to spread at a higher rate, resulting in higher death rates compared to the world.

Because Yemen is the poorest country in the Middle East and North Africa, and since the war caused chaos and destroyed the country’s economy, Yemen is facing unprecedented humanitarian, medical, and food crises (5).

Recommendations and solutions to confront the health care crisis in Yemen during the epidemic

The second wave of COVID-19 may result in deadly consequences in Yemen with the primitive health care system. According to the results of the study, the following recommendations should be considered:

  • Medical support is absolutely necessary to provide essential pieces of equipment such as: PCR machines, diagnostic kits, mechanical ventilators, protective equipment, and medicines to respond to the COVID-19 pandemic in Yemen (3).
  • Training employees of the public and private sectors in various fields of public safety measures to combat infection and the risk of the epidemic, and this is not just for healthcare workers (3).
  • Providing incentives, granting salaries on time without delay, and providing protective equipment for frontline workers in health units to encourage and avoid refusal to work in hospitals receiving cases infected with COVID-19(3).
  • Health facilities must take preventive and public safety measures and implement effective contingency plans to deal with the virus (3).
  • Establishing an epidemiological investigation team of workers or volunteers in the field of health care to combat the epidemic, monitor cases, and achieve a rapid response that includes taking precautionary measures in a timely manner (3).
  • The government should be strict and proactive in implementing public safety plans.
  • Improve laboratory capacity and health facilities to prevent the spread of the epidemic and strengthen entry control points (5).
  • Establish appropriate isolation and quarantine rooms and minimize reliance on dangerous environments in camps and illegal slums (5).
  • Rebuild infrastructures such as health care facilities and provide adequate supplies of water, electricity, and sanitation (5).


The spread of COVID-19 could have dire consequences not only on the already overwhelmed health system but also on food security and agricultural livelihoods. Access to the most vulnerable beneficiaries, which was already difficult before the COVID-19 pandemic, is proving to be a serious challenge in 2020.

Commentary

According to “Save the Children” some hospitals refuse to admit patients who suffer from symptoms of COVID-19, such as respiratory problems and fever. “Hospitals close and patients are deported or left to die”, Joubert said. Due to the lack of responsibility, the number of dead young people aged 40-50 years is increasing, unlike in Europe and the USA.

24 million people (80% of the population) need to be supported with humanitarian assistance, and Yemen is struggling with outbreaks of cholera, chikungunya, and overlapping diphtheria. Schools are closed, but most Yemenis trade freely, for example, in mosques and markets (7).

“The healthcare workforce is more than 50,000 [people] across Yemen, and they do not necessarily get paid consistently, so the humanitarian community, along with the health authorities, has designed a financial support package in several categories”, Masani said.
Yemen, therefore, needs humanitarian and financial funding to support and motivate health sector workers to work efficiently (7).

The WHO and other UN agencies have asked for more support and funding in Yemen to tackle the COVID-19 pandemic, including medical support, equipment, food, and other services (7). The health care system in Yemen is extremely weak due to the fragile infrastructure destroyed by the war and will continue to worsen due to the pandemic and the increased pressure on the health system (6).

According to a report issued by MedGlobal, 97 health care workers (HCWs) have died due to COVID-19 in Yemen. About 18% of the country’s 333 counties do not have doctors, and many workers have not received their salaries for nearly two years. MedGlobal also estimates that there are Now 10 HCWs per 10,000 people (6). It is a catastrophic situation that, if there is no repair, is estimated to worsen, bringing the number of cases to 28 million cases, at least 65,000 deaths, and about 494,000 hospitalizations (7).

The conflict has devastated the health system in Yemen. It needs current humanitarian and collaborative aid that focuses on strengthening the health system to make it prepared for any upcoming health crisis and pandemics.

References

  1. Dureab, F., Al-Awlaqi, S., & Jahn, A. (2020). COVID-19 in Yemen: preparedness measures in a fragile state. The Lancet. Public Health.‏
  2. WHO, Public and private sectors join forces to deliver lifesaving COVID-19 supplies in Yemen, 19 June 2020, Retrieved from https://www.who.int/news-room/feature-stories/detail/public-and-private-sectors-join-forces-to-deliver-lifesaving-covid-19-supplies-in-yemen
  3. Zawiah, M., Al-Ashwal, F. Y., Saeed, R. M., Kubas, M., Saeed, S., Khan, A. H., … & Abduljabbar, R. (2020). Assessment of Healthcare System Capabilities and Preparedness in Yemen to Confront the Novel Coronavirus 2019 (COVID-19) Outbreak: A Perspective of Healthcare Workers. Frontiers in public health, 8.‏
  4. Daw, M. A. (2020). Corona virus infection in Syria, Libya and Yemen; an alarming devastating threat. Trav Med Infect Dis, 101652.‏
  5. Mousavi, S. M., & Anjomshoa, M. (2020). COVID-19 in Yemen: a crisis within crises. International Journal for Equity in Health, 19(1), 1-3.‏
  6. Looi, M. K. (2020). Covid-19: Deaths in Yemen are five times global average as healthcare collapses.‏
  7. Devi, S. (2020). Fears of “highly catastrophic” COVID-19 spread in Yemen. The Lancet, 395(10238), 1683.‏
  8. Van Damme, W., Dahake, R., Delamou, A., Ingelbeen, B., Wouters, E., Vanham, G., … & Van der Borght, S. (2020). The COVID-19 pandemic: diverse contexts; different epidemics—how and why?. BMJ global health, 5(7), e003098. https://gh.bmj.com/content/5/7/e003098.
  9. Violence in Yemen: Thinking About Violence in Fragile States Beyond the Confines of Conflict and Terrorism. https://stabilityjournal.org/articles/10.5334/sta.az/print/
  10. Al-Subari SMMA-S, Khadka S, Mahmood NMA, Alhouzani TMZ, Shrestha D. COVID-19 Tackling in Yemen: An Overview of Scenario. .Journal of Karnali Academy of Health Sciences 2020;3(2).
  11. IOM Yemen: Situation Report September 2020 (3 Nov 2020). reliefWeb. Retrieved from https://reliefweb.int/report/yemen/iom-yemen-situation-report-september-2020.
  12. Coronavirus: Surge in deaths reported in southern Yemen (14 May 2020). BBC. Retrieved from https://www.bbc.com/news/world-middle-east-52669301
  13. Diphtheria outbreak in Yemen: the impact of conflict on a fragile health system (22 May 2019).BMC. Retrieved from https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-019-0204-2
  14. WHO, Yemen: WHO Coronavirus Disease (COVID-19) Dashboard, Accessed 22 Dec2020, Retrieved from https://covid19.who.int/region/emro/country/ye

About the Authors

Sofia Weiss Goitiandia

Sofia Weiss Goitiandia
Sofia Weiss Goitiandia (she/her) is a medical student holding a BA in Natural Sciences (specialisation: Neurosciences) from the University of Cambridge, who will also complete her MSc in Global Health at Karolinska Institutet in June 2021. She has a strong research interest, and has worked on both quantitative and qualitative projects, spanning basic science to a study bridging history of art and public health. She is a keen linguist, with knowledge of six languages, as well as a passionate reader and writer. She also has experience in advocacy work, particularly in the access to medicines field and in promoting gender health equity. She aims to pursue further studies in the subject of philosophy of medicine, and her ultimate goal would be to combine a career in patient-facing medical care with interdisciplinary academic research. She relishes how different approaches can yield new insights on old problems, and—despite her best efforts—remains relentlessly curious about the human condition.

Izzy Edwards

Izzy Edwards is a sixth-year medical student respectively at the University of Cambridge, UK.