Standardized patients: Uniform medical treatment

American Medical News, April 16, 2001

By Susan J. Landers

Should the quest for social justice be part of the public health agenda? How about welfare reform? Increased wages? Many in the public health field favor a broad agenda, and their interest in advancing it has historic roots.

Ever since physicians and others began to concern themselves with public health in the 19th century, they have battled social conditions that they considered part of the problem — crowded, unsanitary housing and factories, and the need for clean food and water.

Public policy has often overlapped with public health, and current concerns with AIDS, breast cancer, smoking and asthma continue the tradition. Science has ostensibly served as a rein on ideological extremes on both the right and left.

But somehow, the challenges now at stake seem to raise difficult and complex questions and trigger controversial responses. Today, for instance, some public health advocates see other social conditions they would like to overcome — poverty, racism and sexism, to name a few. But how far should physicians go in combating these social maladies?

Should physicians and other public health professionals be in the vanguard of the fight to raise wages? Or would they better serve the public by continuing to administer evidence-based medicine to defeat diseases immediately at hand?

Mohammad Akhter, MD, executive director of the American Public Health Assn., argues that there is no clear line between appropriate and inappropriate public health agenda items.

“In the public health community there is a very strong belief that if some of us are unhealthy, the rest of us cannot be healthy,” says Dr. Akhter.

Others argue that setting such goals as defeating poverty and contesting welfare reform are too remote from health care and should be left to policy-makers for resolution.

Theodore Marmor, PhD, professor at Yale University’s School of Management, finds that many of the social changes advocated by health authorities are a “grand diversion from their areas of genuine expertise, and are based on shaky assumptions about inequality.”

Psychiatrist Sally Satel, MD, also argues for limiting the broad reach of public health. “If you’re against welfare reform, fine, lobby against it as a private citizen; don’t make it an agenda item of the APHA,” she says.

Ideology creeps in

In addition, the broad public health agenda comes with a heavy dose of ideology that is not altogether healthy, say Dr. Satel and others.

“Many in the public health elite are putting more passion into the promotion of political doctrine than into direct efforts to improve health,” Dr. Satel writes in her new book, PC, M.D.: How Political Correctness is Corrupting Medicine.

Although many say science is still the driving force behind health policy decisions, others, including Dr. Satel, contest that statement. She questions the soundness of much of the research that drives public health policy today and emphasizes that research into the social determinants of health, “like all research, should be rigorous and the interpretation should be as free of ideology as possible.”

Elizabeth Whelan, ScD, MPH, president of the American Council on Science and Health, says ideology and science are becoming more intertwined in public health and, in fact, “the ideology is starting to take over the science.”

The ideology that Dr. Satel and Dr. Whelan believe is driving public health policy leans to the left and, for want of a better term, has been dubbed “political correctness.”

Dr. Satel believes political correctness is undermining advances in AIDS education, mental health, substance abuse treatment and public health in general by deflecting continued support toward areas that already are receiving sufficient attention, such as women’s health.

Too many researchers in public health are imposing their own beliefs on study data to draw certain conclusions, Dr. Satel says. “There is a problem when you look at all your data in the same direction.”

For example, “We know that health correlates with wealth, but to infer from that that we should redistribute wealth as a health prescription is taking it into a different dimension,” says Dr. Satel. “You could just as easily argue for more free-market opportunities if the point is to make people more wealthy.”

Dr. Whelan also points to an infiltration of left-leaning political correctness. “From my point of view, so many people who call themselves public health educators have contempt for the free enterprise system and for corporations. Their targets, while cloaked in the guise of pursuing public health, seem to be corporations.”

For example, Dr. Whelan faults the approach taken by what she calls “self-appointed public health groups” to fight “purely hypothetical factors,” such as trace levels of chemicals in the environment as part of their battle to defeat cancer. “If I want to prevent cancer, I can go to a textbook on cancer and find out the known causes and focus on them,” she says.

Cigarette smoking and health is another area in which Dr. Whelan sees the public health focus of many groups shifting from health to an anti-corporation mind-set. “My goal is to educate people about smoking and get to the facts. Those practicing politically correct public health seem to want as their target to destroy the corporation,” says Dr. Whelan.

Another downside of the politically correct posture is its diminution of individuals’ accountability for their actions, argue Drs. Satel and Whelan. The news that many more gay black men than white men are infected with HIV should set off alarms in the public health community that messages on safe sex are not getting through, says Dr. Whelan.

Instead, she is concerned that the more sweeping issue of discrimination will be raised, and that attention as well as resources will be diverted from the problem at hand.

Dr. Satel, who works in a methadone clinic in Washington, D.C., also raises the fear that the pursuit of social justice will override individual accountability. “People who practice unsafe sex, stick dirty needles in their veins or fail to take their TB medications daily are too often seen as passive victims of malign social forces,” she writes.

Addressing the root causes

However, many public health advocates argue that discrimination could well be a primary problem in many situations and must be considered.

“What we are saying is that there are very powerful determinants that influence a person’s capacity to demonstrate individual responsibility,” counters Robert Lawrence, MD, associate dean for professional education at Johns Hopkins School of Public Health. “The public health community has not abandoned the concept of individual responsibility and individual risk behavior.”

For example, when counseling young people in rural North Carolina or inner-city Boston to abandon cigarette smoking, change their unhealthy diets or use seat belts, Dr. Lawrence says they respond with: ” ‘You know, doc, I don’t expect to live until I’m 30, so what difference does it make?’ ”

That pessimism results from opportunities denied, inadequate schools, inadequate social support and poor wages, says Dr. Lawrence.

There is a need in public health to focus on those “upstream factors,” adds Lisa Berkman, PhD, chair of the Dept. of Health and Social Behavior at Harvard University’s School of Public Health. “I think what the science has shown us is that individual behaviors are embedded in a social environment, and unless we have a better understanding of what motivates people and what sort of resources and constraints they have, we will never get people to make the right kinds of choices,” she adds.

“Often, the most fundamental thing you can do to improve a public health situation is to get at the root cause,” says Hardy Loe Jr., MD, MPH, associate dean for community health at the University of Texas School of Public Health. “One of the biggest causes of death, disability and lack of care is inadequate wages.”

Political correctness has its place

Many believe that being politically correct is often just that — correct. “Generally, it is appropriate to be politically correct when addressing issues of political sensitivity, whether that has to do with matters of gender, race, ethnicity, sexual orientation or medical conditions,” says Ron Davis, MD, director of the Center for Health Promotion and Disease Prevention at the Henry Ford Health System in Detroit.

“Of course one can argue that it can be taken to an extreme and go overboard at times,” notes Dr. Davis, who is also a former medical director for Michigan’s Dept. of Public Health.

Political correctness, although it might not be identified as such, plays a role in many policy debates, including those at the AMA House of Delegates meetings. One such debate over voluntary vs. mandatory HIV testing of pregnant women stretched over two or three years, notes Dr. Davis, who was chair of the AMA’s Council on Scientific Affairs at the time.

Those arguing for mandatory testing made the point that HIV must be treated just like any other communicable disease and shouldn’t be given special status. Those favoring voluntary testing argued that HIV was unique and that people who test positive face discrimination in health insurance and employment.

The debate over such issues will go on, and APHA’s Dr. Akhter says he appreciates the heightened attention brought by Dr. Satel’s book.

“The debate brings into focus the need to look at the evidence, do the research and find the truth, the causes and treatment,” he says.

Dr. Satel says she had hoped her book would stimulate debate, and notes: “Mission slightly accomplished on that.”