By Ashish Premkumar, Allison Barker, Amanda DeLoureiro, MPH, Leela Sarathy, Daniel A. Dworkis
As medical students, we operate in a world of graduated clinical responsibility, traversing the divide from taking vitals to complex differential diagnoses and unsupervised minor procedures. We are taught that as our skills and sophistication grow, we will be caring for increasingly complex patients. When patients suffering from violations of their human rights are mentioned, often in the context “global health,” they are almost inevitably placed at the end of this graduated spectrum. We are told if you learn to take care of the “normal” patients, then eventually you will figure out how to care for the patient whose very existence has been shattered. For now, you do not have to worry about it; just learn how to hold the scissors properly when repairing this laceration.
There is a sound logic in this, as holding scissors correctly is indeed difficult in the beginning, but as medical students working in the largest safety-net hospital in New England, the reality is that we are regularly exposed from the beginning of our training to patients suffering from significant violations of their human rights. These patients, our patients, whose rights have been violated by acts of interpersonal and systemic violence, are impossible to ignore, impossible to put off until we are more sophisticated. They need us now; they need us to learn how to care for them.
We are not unique in recognizing this need. Article 44, General Comment 14 of the International Covenant on Economic, Social, and Cultural Rights requires that states must “provide appropriate training for health personnel, including education on health and human rights.”1 Panosian and Coates note in their 2006 editorial “The New Medical ‘Missionaries’” that medical students are “[…] [h]ungry to discuss diseases of poverty as well as international policy and aid programs. In the curricula at most medical schools and postgraduate institutions in the United States, these topics receive little time and attention.”2,3 Furthermore, when medical schools do explicitly address issues of health and human rights, it is usually in the context of global health electives, or relegated to become part of the so-called “hidden curriculum,” the body of knowledge passed informally from doctor-to-student or student-to-student. Physician interest and student self-selection are major forces promoting this training; education that is provided is subject to both faculty interest in the subject matter and perseverance of interested students in seeking out elective coursework.4 As a result, the fund of knowledge relating to health and human rights is often fragmented and is rarely an integral feature of medical education in many schools.
However, in a rapidly globalizing society, where refugees from Somalia end up in Section Eight housing in Boston or illegal migrant workers in the Gulf suffer from asthma due to substandard living conditions, issues that once were designated “international” quickly become local. Today, human rights abuses and their sequelae find themselves in our primary care panels, our operating rooms, and our emergency departments with a frightening regularity. Teaching about human rights abuses as issues beyond America’s borders leaves our physicians and medical students unprepared to meet the needs of increasingly complex individuals living in this country who have faced similar challenges.
The human rights paradigm—specifically legal, advocacy, and public health approaches5 — gives us a framework in which to understand and rectify our patients’ circumstances and should become a larger component of undergraduate medical education. This view has been advanced previously by multiple organizations including the American Medical Association, Association of American Medical Colleges, American College of Physicians, and World Medical Association, who collectively have called for physicians to be competent in and to advocate for human rights issues, including those of socioeconomic inequality, social justice, and violence.6, 7, 8, 9, 10 Additionally, Cotter et al. noted that 62% of deans of medical schools and schools of public health want these issues taught to their students.4 Major barriers noted were lack of funding, lack of trained personnel, and most notably, lack of time in the curriculum. And while medical students need to be trained to identify and understand the theoretical aspects of human rights violations, we also must begin to form a critical praxis towards addressing these issues in our patients. Human rights training and advocacy, to quote Gruen et al., “[…] bridge the gap between rhetoric and reality—the rhetoric of social responsibility espoused in aspirational statements of professionalism and the realities of medical practice and the mechanisms by which social factors affect the health and care of patients.”11
What we want to emphasize is that this call for further education is not merely coming from the top-down—from teacher to student—but also from the bottom-up. We not only see a need for further education in the connection between human rights and health, but we also urge our colleagues both at home and abroad to realize that these issues are not in just in the confines of certain geopolitical spheres or relegated to historical aberrances. These problems currently exist, and moreover, they exist in our hospitals. While the barriers to including this training mentioned above are not insignificant, we believe this formal training is crucial to our aspirations to become socially conscious physicians. Without it, we may understand how to hold our scissors correctly while repairing a laceration, without ever understanding why our patient was cut or what we can do about it.
The authors are students in the Advocacy Training Program at Boston University School of Medicine, 700 Albany Street, Boston, MA.
For correspondence, e-mail email@example.com.
1 International Covenant on Economic, Social, and Cultural Rights. G.A. Res. 2200 (XX) (1966). Available at: http://www.un-documents.net/icescr.htm.
2 International Covenant on Economic, Social, and Cultural Rights. G.A. Res. 2200 (XX) (1966). Available at: http://www.un-documents.net/icescr.htme. 354/17 (2006), pp. 1771-1773.
3 L.E. Cotter et al. “Health and Human Rights Education in U.S. Schools of Medicine and Public Health: Current Status and Future Challenges.” PLoS ONE 4/3 (2009), pp. e4916.
4 University of Southern California Global Health Institute. “Global Health and Human Rights Syllabi Database.” Available at http://globalhealth.usc.edu/Home/Resources/Pages/Syllabi%20Database%20Overview.
5 S. Gruskin, “Rights-based approaches to health: Something for everyone,” Health and Human Rights 9/2 (2006), pp. 5-9.
6 World Medical Association, Resolution on the inclusion of medical ethics and human rights in the curriculum of medical schools world-wide (1999). Available at http://www.wma.net/e/policy/e8.htm.
7 American Medical Association, Declaration of professional responsibility: Medicine’s social contract with humanity (2001). Available: http://www.ama-assn. org/ama/upload/mm/369/declaration.pdf.
8 L. Snyder and C. Leffler, “Ethics manual: fifth edition,” Annals of Internal Medicine 142/7 (2005), pp. 560-82.
9 L. Rubenstein, “The human rights imperative in medical education” Association of American Medical Colleges (2004). Available at http://www.aamc.org/newsroom/reporter/ jan08/viewpoint.htm.
10 American Association of Medical Colleges, Behavioral and social science foundations for future physicians (2012). Available at https://www.aamc.org/download/271020/data/behavioralandsocialsciencefoundationsforfuturephysicians.pdf.
11 R. L. Gruen, S. D. Pearson, and T. A. Brennan, “Physician-citizens: Public roles and professional obligations,” Journal of the American Medical Association 291/1 (2004), pp. 94-98.