Social Medicine and the Coming Transformation: a Manual for Career Path 2.0

Who practices social medicine? As third-year medical students rotate through their clerkships, they sort themselves into future pediatricians, psychiatrists, surgeons, radiologists, etc. No medical student plans to enter the specialty of social medicine. Nursing is a discipline in its own right, but nurse practitioner students learn to function as clinicians, much like physicians. Students in public health plan to pursue epidemiology or environmental health or maternal and child health. (Or they are obtaining an advanced degree to advance their careers in their own discipline.) They don’t study public health to pursue social medicine. For one thing, there’s that word “medicine,” which all good public health practitioners view as anathema. Finally, social science students may become medical sociologists or medical anthropologists, but they don’t usually have the career option of becoming social medicine practitioners.

With Social Medicine and the Coming Transformation, Howard Waitzkin, Alina Pérez, and Matthew Anderson, give us a how-to manual on how to become a social medicine practitioner. They invite all of us involved in health work to re-invent ourselves and adopt social medicine as career path 2.0. It should become, as the British say, the primer on the subject.

The clinician sees patients one by one, assigns diagnoses, and chooses appropriate therapies (which might be medications, surgical procedures, talk therapy, or rehabilitation). This is the essence of a medical education, refined further during postgraduate training. The focus is on the individual patient, on the biological aspects of the individual human organism. The more reductionist and mechanistic, the better. Simply follow the “best practice” algorithms, approved by the insurance corporation. Blood pressure too high? Reduce the afterload! Or, tamp down the sympathetic nervous system! Even psychiatry has fallen prey to mechanistic paradigms. Feeling sad? Ramp up the synaptic re-uptake of serotonin!

In contrast, Waitzkin, Pérez, and Anderson see social medicine’s central insight to be “that disease is both a biological phenomenon and a manifestation of specific social conditions,” and that both must be treated, not just the human organism. Social structures are integral to the problems any discipline practitioner face every day. Social conditions, the structural deteminants of health, must be cured, too. It is this central insight “that informs the work of social medicine.” (pp. 6-7)

What, then, distinguishes the social medicine approach from that of public health? Public health practitioners shake their heads sadly at the reductionist follies of physicians (and grumble about them grabbing all the money). Don’t the benighted physicians recognize the social determinants of health (SDOH)? Obviously, people are sicker or healthier depending on “risk factors” such as their “race,” their income, their zip code, their education, or their sexuality. However, underlying these now more widely accepted SDOH, are the fundamental economic structures of society, which require a political reorientation if SDOHs are to be treated and improved.

There was a time when uttering “social determinants of health” might have earned one the label of “socialist nut job.” But nowadays, the woke programmers of electronic health records are happy to substitute “SDOH” where “personal profile” or “social history” used to be – in the history and physical representation of the patient (though one rarely finds much more than smoking and alcohol use listed in this section).

The social medicine practitioner is dissatisfied with this sort of SDOH framework, which grants reality to (i.e. reifies) categories that are, in fact, fluid and historically contingent. (The concept of “reification” is usually attributed to early 20th century Hungarian Marxist Georg Lukacs.) Take, for instance, “social class.” As Rudolf Virchow proposed in the 1840s, a central tenet of social medicine is that class is the most important cause determining the health outcomes of populations.

“Class” is a reified category and must be dealt with dialectally. The U.S. working class today, for example, is largely female, non-white, and works in the service industry. For the social medicine practitioner, class remains the single most important factor that leads to the social determination of health. Waitzkin, Pérez, and Anderson identify the forefathers of social medicine as Friedrich Engels, Rudolf Virchow, and Salvador Allende. Engels identified capitalism as determining the too early and an unnatural death (“its deed is murder”) of the working-class in England in 1845. Virchow identified poverty, lack of education, and lack of democracy as determining the outbreak of typhus in Upper Silesia in 1848. The Unidad Popular platform, on which Allende ran to become President, identified poor sanitation, housing, nutrition, and working conditions as determining the poor health of Chileans.

The perspective of social determination leads to different data, interpretations, and recommendations for change. Social determination views society as a totality, rather than as a sum of individuals, and the overall characteristics of a society require analysis in studying the impacts of social conditions on health. Instead of health or illness as dichotomous categories, social determination considers health–illness as a dialectic process. A dialectic vision requires a multilevel analysis of how social conditions, such as economic production, reproduction, marginalization, and political oppression, affect a dynamic process of health–illness among different groups within a population, such as workers versus capitalists, poor versus rich, women versus men, and ethnic–racial minorities versus non- minorities. Rather than processes of persuasion and assessment of evidence, changes in policies and in societies emerge from social contradictions and the social movements and conflicts that arise from those contradictions. Hierarchies of determination, production, and reproduction at the societal level impact health–illness, as opposed to individual-level variables that measure risk. Such hierarchies involve power relations, accumulation of capital, and discrimination (classism, racism, sexism) that create inequality, exploitation, and chronic stress, and these conditions lead to illness and early death. Lasting improvements emerge through societal transformation, for instance, transforming the structural characteristics of capitalism that generate illness, early death, environmental degradation, war, and multiple injurious effects on humanity, other forms of life, and the earth. (p. 53)

The social medicine practitioner does not need to be a clinician. The social medicine practitioner does not need a background in public health. Indeed, the social medicine practitioner does not need a background in health at all. The social medicine practitioner might, however, need an improved consciousness, recognizing ideological constructs that prevent her from seeing social totality. The social medicine practitioner researches the ways in which social forces such as working conditions, education, health care infrastructure, food production and distribution, language and culture influence health and disease. The social medicine practitioner then intervenes vis-à-vis those social forces.

As concrete examples of how social medicine is currently practiced, social medicine core concepts and tools are now being applied in clinical practice, as illustrated in the Case Studies in Social Medicine series in the New England Journal of Medicine. This series imparts core concepts in social medicine and suggests steps for addressing specific problems that arise in clinic practice. The intent is to show U.S. clinicians the importance of investigating, analyzing, and addressing social forces. In chapter 5 “Social Medicine in the United States,” Waitzkin, Perez, and Anderson outline the historical movements to improve the lives of workers, women, and children and the efforts to deliver clinical care to them via community health centers. They note that social medicine has a “large unfinished agenda” in the U.S.

In the way that many of our fellow animal species, particularly those that are either predator or prey, have visual cortexes particularly suited for detecting movement – the social medicine practitioner needs to have an eye for the “dynamic process of health–illness.” The Capitalocene Age does not move at geologic time scales. Before we realized what was happening, we found ourselves well into the Sixth Extinction. Indeed, the dialectical effect of our human species on the environment, as well as the effect of the changing environment on our species ability to survive – is being borne out in horrific fashion.

Grotesque inequalities constitute an existential threat to humanity. A few billionaires own as much as half the people of the planet. How is it possible to even speak of health in the face of such a farcical “system” that concentrates such wealth and power in the hands of a few white men? The Intergovernmental Panel on Climate Change released its most recent report on August 7. It tells us that the world is on fire, and perhaps you live somewhere where that’s obvious just looking out the window. More of the planet will not have enough water for human habitation. There will be yet more people migrating. The U.S. leaves Afghanistan to prepare for the coming war with China. Or with North Korea. Or Iran. Or with Russia. Or all simultaneously. The threat of nuclear war looms ever closer. We don’t need bombs and missiles and Death Stars to set the world aflame. The world is on fire already.

We are in great need of all kinds of social medicine practitioners – to stop the burning of fossil fuels. To get rid of nuclear weapons. To develop green technology. To distribute resources equitably. When do we need to do this? Hmm, let’s see . . . how about now? As Dr. Martin Luther King, Jr. said in his speech “Beyond Vietnam,”

We are confronted with the fierce urgency of now. In this unfolding conundrum of life and history, there is such a thing as being too late. Procrastination is still the thief of time. Life often leaves us standing bare, naked, and dejected with a lost opportunity. The tide in the affairs of men does not remain at flood – it ebbs. We may cry out desperately for time to pause in her passage, but time is adamant to every plea and rushes on. Over the bleached bones and jumbled residues of numerous civilizations are written the pathetic words, “Too late.”

Social medicine practitioners deal with disease by taking a step back and examining the root causes of why the people become sick. The social medicine practitioner continues to ask questions until she gets down to the fundamental causes of illness—the social structure. In that social medicine seeks to overturn oppressive social structures, social medicine practice is revolutionary medicine. In Social Medicine and the Coming Transformation, Waitzkin, Pérez, and Anderson propose that the central work of social medicine is creating conditions that foster good health and access to needed health services, impossible under the current capitalist system and only realizable in post-capitalist society. The authors also suggest something of a Rinky-Dink Revolution, safe and feasible things that we can do now to divorce ourselves from capitalism, construct a ”solidarity economy” and conduct “creative acts of resistance and nonparticipation in the global economic capitalist system,” and live in an ecologically sustainable manner. Will they be enough?

Seiji Yamada is a family physician practicing and teaching in Hawaiʻi. Arcelita Imasa is a family medicine resident physician in Hawaiʻi. Gregory Maskarinec is an anthropologist.