Prof. Abebe Bekele: Social Justice Must Be the Foundation of Medical Education

Recently, Stanley Goldfarb from the University of Pennsylvania penned an op-ed in the Wall Street Journal titled, “Take Two Aspirins and Call Me By My Pronouns.” In this article, the author challenges the recent changes in medical education curriculum calling for a greater emphasis on social justice. Goldfarb asserts that this new model of education is “coming at the expense of rigorous training in medical science” and that educational institutions need to revert back to the pedagogy from the days of Hippocrates so that we will produce “technically proficient and responsible physician corps.” 

We wholeheartedly agree that we need competent doctors and professionals, this is not up for debate. We strongly agree that today’s doctors should be equipped with the necessary competencies that prepare them to handle existing and emerging health challenges, diagnose and treat a variety of diseases and offer state of the art treatment.  However, the meaning of “competence” has evolved beyond the training of “health technicians” as we have advanced in our understanding of social medicine and the social determinants of health. We know now that it is not enough to simply have technical competence. As Goldfarb’s colleagues at the University of Pennsylvania have pointed out in a follow-up piece, the traditional model of medical education has led to vast inequalities in the American health system. These disparities are even more magnified in the developing world — take Africa, for example — where infectious diseases such as HIV, TB and malaria, neglected tropical diseases, massive burden of surgically treatable diseases including trauma, high maternal mortality and higher levels of poverty conspire with very limited access to health care. 

In Africa, child malnutrition is a major cause of death, contributing to 45% of deaths under the age of 5 in the region. Malnutrition, from the vantage point of the technician doctor, is a straight forward diagnosis. It results from a lack of dietary nutrients (mainly proteins) in the body due to a poor diet and is treated by a diet rich in protein and rehydration. The “competent” doctor, by Goldfarb’s definition, would admit the “case”, provide this treatment and discharge when recovered, only to see them return back a few months later with the same degree of malnutrition. We argue that physicians must be able to look beyond the traditional paradigms in health care and ask what social factors have led to this child’s poor diet and how he or she as a health care professional can prescribe a treatment that takes into account the patient’s social context. 

Africa is also seeing a rise of multidrug-resistant tuberculosis (MDR TB) in the region. TB occurs in greater numbers in poor communities due to factors such as poor living conditions and overcrowding, malnutrition, and lack of access to health care. Even if a TB patient ends up getting care at a health facility and does receive the prescription for the medications, if the doctor does not understand the social determinants and context of that patient, the treatment could be rendered ineffective. How can the doctor make sure the patient is adhering to the treatment? Does the patient talk the 8-10 tablets per day for 6-8 months? Does the patient have access to dietary and social support (two factors that are decisive for the recovery of the patient)? Partners In Health saw great success in reducing the mortality rate of MDR TB patients through the use of community health workers in the treatment plan to treat the socioeconomic factors at play. 

As we have developed in our understanding of what causes disease and illness and the barriers to effective treatment, the words “access” and “quality” as they relate to health care have changed in their meaning. Five billion people –more than two-thirds of the world population- do not have access to safe surgical care when needed. Access is defined by the Lancet Commission on Global Surgery as (1) physically available in a timely manner, (2) having the necessary capacity, (3) being of sufficient quality and safety, and (4) being affordable. “Access to health care” no longer simply refers to the existence of a health center. It takes into account whether or not a patient has enough money to get on a bus to reach that health center, or if they have someone at home who is able to take care of their children while they seek treatment. “Quality health care” no longer equates to technical competence. It encompasses the patient’s entire socioeconomic — and yes, political — factors that contribute to their overall health and well-being. 

The University of Global Health Equity (UGHE) was created as a response to these gaps in traditional medical education. Our belief is that in order to achieve equity in health care we must reinvent health care delivery, and doing so requires a radical transformation in health care education. This education must not only include components of social justice, but they must be at the center of the curriculum. Medical students should graduate ready to treat not just diseases and symptoms, but the structural inequalities that contribute to them. 

Goldfarb would argue that a university like ours should not exist, or that it comes at the cost of patients. We would argue that medical education that is not centered around social medicine is the one that puts patients at risk. We believe that health care is a human right, and if we are to believe that, then we must put forth a model of medicine that is rooted in our humanity and treats everyone equitably. Our philosophy of education — one built with an equity agenda — will produce physicians, nurses, and other health care professionals that are not only technically competent but empathetic in their approaches to patient care and relentless in their pursuit of building stronger, more equitable health systems. It is these individuals that will lead a new generation of global health leaders in realizing this idea that health care is a human right. 

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