Physicians as advocates: an enduring calling

“Medicine is a social science and politics is nothing but medicine on a grand scale”¹

Many MJA readers will be familiar with this oft quoted phrase from the 19th century German physician Rudolf Virchow. In his landmark report of a typhus epidemic, Virchow pointed out the links between poverty and the spread of disease. The role of the medical profession, it follows, is not simply to treat individual patients but to also attend to the social conditions that underpin poor health outcomes.

Consideration of the social determinants of health, as we now call them, is a fundamental part of contemporary public health research and practice and an area the MJA frequently publishes on. In this issue of the Journal, for instance, research by Rubenis and colleagues² investigates place-based disparities in care for cardiovascular diseases. They find that despite recent improvements, patients living in regional and remote areas of New South Wales admitted to hospital with heart failure experience persistently higher in-hospital mortality compared with their metropolitan-dwelling counterparts. Likewise, writing in a perspective article, Robertson and colleagues³ explore the many barriers that exist to research participation by people with vision impairment and describe strategies for improving participation by changing information provision and data collection methods.

Although it is widely accepted that the state of our social world has an enormous influence on health, the role of health experts in moving beyond merely describing and explaining to seeking to transform social conditions to improve health remains contested. This is especially when powerful interests are at play. In such cases, it is common for physicians and researchers to be extorted to stay in their narrowly defined biomedical “lane”, or for those within the profession to worry about tainting their appearance of objective, evidence-driven thinking by engaging in debates of a political nature.

Bilgrami and colleagues⁴ address this tension in an article on armed conflict and the role of physician advocacy. Globally, attacks on health care — such as the killing, kidnapping and arrest of health care workers, hijacking of medical supplies, obstruction of patients from accessing care, and the bombing, looting and occupation of health facilities — are on the rise. Despite these devastating events, the authors note “most medical associations and societies have been inconsistent when it comes to advocating for the protection of health care workers in conflicts. An argument commonly put forth in recent years is that such organisations must remain apolitical”. Bilgrami and colleagues contrast this approach with notable historical and contemporary examples of successful physician advocacy efforts, as well as with their view of the norms and responsibilities at the heart of ethical medical practice. Ultimately, they conclude that “physicians have been unconscionably silent in recent years and must now integrate professional and political activities if they are to live up to the highest ideals of the profession”.

There are lessons here that extend far beyond the issue of armed conflict. In the United States, for instance, the coalescence of anti-science and anti-human rights agendas under the Trump administration has placed academic independence and public health under attack, including with direct effects in Australia.^{5, 6} Researchers and practitioners are facing very tangible consequences for engaging with the social determinants of health, be it around gender, sexuality, race, or health inequities more generally.⁷ Grants are being cancelled.⁸ Public health programs are being dismantled.^{9, 10} Universities are being intimidated.¹¹ Credible health information is being censored^{12, 13} and purveyors of misinformation are being elevated to high places.^{14, 15} What recent events in the US have demonstrated is that regardless of whether scientific and medical institutions seek to appear apolitical, political actors nonetheless deeply appreciate the power that health and medical experts hold in our societies and are prepared to act accordingly in pursuit of their dangerous agendas. Virchow's instruction to the medical profession is as relevant today as it was over 150 years ago.