Industrial Psychiatry Journal

EDITORIAL
Year
: 2018  |  Volume : 27  |  Issue : 1  |  Page : 6--10

Clinical medicine to social medicine


Antonio Ventriglio1, Pookala Shivaram Bhat2, Dinesh Bhugra3, Kalpana Srivastava2,  
1 Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
2 Department of Psychiatry, AFMC, Pune, Maharashtra, India
3 Department of Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK

Correspondence Address:
Dr. Pookala Shivaram Bhat
AFMC, Pune - 411 040, Maharashtra
India




How to cite this article:
Ventriglio A, Bhat PS, Bhugra D, Srivastava K. Clinical medicine to social medicine.Ind Psychiatry J 2018;27:6-10


How to cite this URL:
Ventriglio A, Bhat PS, Bhugra D, Srivastava K. Clinical medicine to social medicine. Ind Psychiatry J [serial online] 2018 [cited 2018 Dec 13 ];27:6-10
Available from: http://www.industrialpsychiatry.org/text.asp?2018/27/1/6/243320


Full Text



Medicine is often described as the second oldest profession. Ever since the times of Hippocrates, physicians have been told and taught to “ first do no harm to their patients.” There is no doubt that appearance and disappearance of diseases affect the clinical practice of medicine. For example, elimination of smallpox from across the global population has meant that several generations of doctors have not seen a single case and the immunization against smallpox is not needed at all. These changes in epidemiological presentations, in turn, are also influenced by social factors. Human beings by and large are social animals. At the core is the human being surrounded by family members, neighbors, friends, peers and then at periphery are members of kinship, culture and society. Families can be both supportive and trauma inducing. As Tolstoy famously said, all happy families resemble one another, and each unhappy family is unhappy in its own way (Tolstoy 2014).[1] Morson in the introduction to this translation argues that happy families are happy because they have no history.[2] His argument is that happy families resemble each other because there is no story to tell about them whereas unhappy families all have stories to tell and each story is different. If we apply this conundrum of unhappiness to sickness, disease, or illness, it becomes clear that each individual and each family respond very differently to stress induced by illness. Their personal and financial resources will affect this. There is no doubt that unhappiness emerges from a number of sources including history of trauma, poverty, migration, asylum, etc. contribute to unhappiness. It can be argued that response to the same treatment in different individuals can be influenced by social factors.

Smallpox disappeared in response to mass vaccinations even though samples are being kept in some laboratories. Social factors and political changes may well lead to the return of this disease as an act of terror. The spread of infectious diseases is strongly influenced by factors such as poverty and overcrowding. It is the society through its representatives that dictates not only practice of medicine which occurs in the context of society's needs and demands but also how society sees medicine and how the training of health practitioners and delivery of health care are funded. It is the society which determines what sickness is and how this is to be managed and who manages it as well as how structures of health-care systems are created and maintained. In many countries including India, wide acceptance of alternative or complementary systems in addition to or in preference to allopathic systems determines how much funding and resources are made available. Depending on the explanatory models and understanding of illness behaviors, locally society will determine what models of care are preferable and acceptable. Society and cultures also influence models of distress and potential explanations for distress. There is no doubt that any resource allocation within which medicine is to be practiced remains a matter of social choice and should be seen as related to a number of social and epidemiological factors as well as implicit social contract between medicine and society represented by stakeholders such as politicians and policymakers as well as families and carers of patients and patients themselves.

There is no doubt that medicine as one of the original professions carries with it a moral and ethical imperative. The social contract between the profession and the society at large needs to be renegotiated accordingly to cultural values and values of social justice as a matter of urgency. As part of the social contract negotiation, such a process must include those who are most in need of health-care patients, their families, and carers on the one hand. In reality, they are represented by the stakeholders such as politicians and policymakers, but their voices and needs must be recognized. On the other hand, medical profession also needs to be clear about its expectations as seen by their patients, carers, and family members of patients. A major issue is that such a contract is implicit and not explicit. However, making it explicit brings with it other imperatives.

It is obvious that human beings are born into cultures and social settings. They develop and grow up in social milieu which helps form their identity as a whole but also micro-identities related to gender, sexual orientation, religion, etc. They learn about social interactions and these, in turn, define them. Illnesses interfere with these social interactions. It is recognized that the development of the brain with its complex structures is affected by social factors and interactions, which can also lead to dysfunctions of both the brain and the body. Furthermore, the Cartesian mind–body dualism is an artificial dichotomy between physical and mental health. There is increasing evidence that social determinants of health play a major role in the genesis of both physical and mental illnesses.[3] These social determinants include urban factors, poverty, unemployment, overcrowding, and even factors such as lack of green spaces, among others. Society itself plays a big role in defining many types of illness and deviance, which dictates allocation of resources needed to manage such “abnormalities.” However, recent developments in our understanding of geopolitical factors related to the impact of disasters – be they human-made or natural, climate change, conflict, and other factors leading to mass migration, poverty, and asylum seeking – have become increasingly relevant. The clinical practice of medicine is in the context within which society determines the structures, policies, funding, and environment within which therapeutic encounters take place and care is provided.

The moral and ethical case for treating illnesses is beyond question. However, often, it is not clear what the exact function of medicine and doctors is. Of course, there is their role as a healer. Illnesses are caused by trauma, infections, immune problems, lifestyle, nutritional causes, environmental causes, etc. The social context of all these causes is critical in our understanding of the causation as well as the management of illnesses. However, part of this context depends on social contract between the individual and the society on the one hand and between the doctors and the society on the other hand. Social contract then feeds into social justice or health justice for people who may be suffering from one or more of these illnesses. From Hobbes to Locke and Rousseau, theory of social contract has been enormously influential. More recently, Rawls and others have explained the ideas behind the concept. This has led to clear challenge to the definition of health as promulgated by the World Health Organization which focuses on health as primarily the “absence of diseases.”[4] There are several objections to this. First, as people are living longer, often they live with complex comorbidities and also chronic conditions many of which wax and wane. Second, other critics of the definition quite rightly argue that the social domain is about individuals' ability to manage one's life by fulfilling their potential and obligations with a degree of independence even though there is no clear definition or agreement of the exact degree required to be identified as healthy.[5]

It could be argued that health in this particular domain is a dynamic balance between opportunities and limitations and is directly affected by social and environmental conditions. Thus, the social domain is a relevant aspect of health and the practice of medicine. We believe that social domain is much more pertinent in the understanding and management of medical illnesses and can be seen as a crucial etiological factor in a significant number of medical conditions. Virchow [6] maintained that illness (of any kind) was an indictment of the political system and that politics was nothing other than medicine on a large scale.[6] The idea that medicine is social is not new or recent.[7],[8],[9]

Recent advances in our understanding of such areas as mirror neuron systems reflect the importance of social cognition that governs human social interactions.[10] Social stressors can lead to changes in the cerebral substrate and affect neurohormonal milieu. Even the organic conditions such as dementia which have more clearly identifiable biological substrate are not independent of social factors such as economic and educational status, life events, etc. The integration between mental and physical well-being is important for a number of reasons. It is well recognized that if patients with hypertension or diabetes develop depression, it becomes difficult to manage physical illnesses unless both conditions are treated effectively.

The relationship between medicine, society, and management of illness is complex. A more complicated issue related to this relationship is the role of the doctor – their professional values and their role as professional medical expert, manager, advocate, scholar, communicator, and collaborator.[11] The importance of public health is often ignored, even in the face of evidence of strong links between illnesses and social determinants including poverty, deprivation, overcrowding, unemployment, nutritional deficiencies, and lifestyle illnesses such as obesity. The role of social conditions causing physical and psychiatric disorders often gets ignored, and advocacy for patients is not as strong and vocal as it could/should be.

Fathalla suggests that as more physicians became technically oriented, the less socially conscious they have become. As poor housing, overcrowding, and other factors contributed to tuberculosis, physicians used clean air and sanatoria as treatment. Once bacillus was discovered and anti-bacillus treatments made available, curative aspects became more operative than social management.[12] The social medicine model is applicable to many specialties in medicine and surgery. Doctors as managers of society's concerns and expectations need to continuously evolve in their professional development and through regular updates and training.[13]

In psychiatry, McHugh and Slavney offered an interesting perspective in explaining mental disorders.[14] These four perspectives include disease, dimensional, behavioral, and life story perspectives. However, these can also be applied to the rest of medicine with suitable amendments. It is apparent that whereas disease perspective focuses on clinical entity, pathology (perceived or real), and etiological factors, dimensional perspective focuses on the extent and may apply to symptoms such as the severity of pain. The consequences of symptoms, illness experience, and distress are reflected in behavioral paradigms. These perspectives are self-evidently influenced by social factors. Life story perspective is narrative and can be both socially determined as well as socially influenced. Life story perspective also aims to provide a clear framework for understanding the developmental aspects of the individual as well as getting a perspective based on narrative. It is not surprising that these perspectives are based on both cultural and social values as well as social domains. It can be argued that whereas illness by definition focuses on a patient's inability to function properly, it is the patient who decides and determines levels of poor functioning within a tight framework of “social functioning” as determined and expected by the culture or society. Many previously commonly diagnosed disorders such as infectious diseases have given way to lifestyle disorders both in the developed and developing countries over the past few decades. It is hypothesized that these changes are largely due to changes in social conditions. Further exploration is required to determine whether symptoms have simply altered in response to changes in social expectations on the individual within a rapidly changing social structural system, thereby eliminating or creating new conditions.

Porter reminds us that in the 19th century in Western countries, social reformers were keen to increase the political role of medicine and attempted to introduce this to undergraduate training of medical students.[15],[16] In many developed as well as less developed countries, the curriculum pays only lip service to this idea. In many parts of the world including India, preventive and social medicine forms a major part of training at undergraduate level and as part of the internship year. However, within such curriculum, there is quite rightly a major focus on infectious diseases, physiological disorders, and occupational health, but little emphasis is placed on social aspects of disorders such as the nature of employment and lifestyle conditions.

Therapeutic encounter of any kind in any medical specialty and in any clinical settings has at its core the patient's and their carers' perspectives and expectations. Patients' and carers' beliefs, explanatory models, past experiences, culture of the health-care system, and the medical profession itself are some of the key aspects of patient engagement. Stonington and Holmes proposed that health-care systems play a significant role in the therapeutic encounter and engagement.[17] As mentioned above, the models of health care are designed and dictated by the social systems. Social medicine includes social and cultural studies of health and medicine and social determinants.[18] Biological vulnerabilities play a large role in social development and disorders and set off social determinants which, in turn, can influence biological factors.

Malekpour observes that infants upon birth are far more competent, social, responsive, and more able to make sense of their environments than previously imagined.[19] He goes on to note that infants can only be competent in the context of a relationship. Thus, early social interaction starts to build individual identity.[20] It has been that even for rodents, housing has profound effects on their brain structures and that such behavioral and genetic manipulations can be affected by rearing conditions.[21],[22],[23],[24] Thus, there is a clear indication that social factors affect behaviors and imprinting can form long-term social preferences. Even within the animal experiments, the focus shifts to biological and structural changes ignoring the “social” factors such as overcrowding and “housing.”

Although a two-hit theory has been described in the context of psychiatric disorders, postulating that genetic defects ( first hit) by themselves may not lead to illness, but this may be expressed following interaction with other genetic, biological, or psychosocial environmental variable (second hit) leading to expression of pathological mutation and brain changes.[25] The same model can be applied to other medical conditions. Epigenetics is a relatively new field which involves understanding how environmental influences modulate gene activity. Stress vulnerability response models may focus on vulnerability at micro-levels through epigenetics and may support understanding of this process. Factors such as poor parenting, adverse childhood experiences such as abuse, neglect and bullying affect social development thereby increasing future vulnerability to various severe mental disorders.[26],[27]

We propose that curricula for all illnesses be they physical or psychiatric must include sociocultural dimensions of individual experiences and distress in both the diagnostic and management frameworks. The impact of patient narratives in enabling clinicians to make sense of this narrative and life story including developmental history in the context of development of distress and illness to understand the role and impact of social factors in the genesis and then utilize this in creating management strategies with an understanding of underlying social factors on the etiology and biological vulnerabilities are crucial aspects of management in medicine. The practice of medicine as a whole must be seen in the context of social environment and social determinants. Knowledge and evidence of this must be applied more rigorously in all diagnostic frameworks and management capabilities. This may help patients' understanding of their own distress and reduce clinicians' emphasis on biological model of explanations. We recognize that this may not be always possible due to pressures of time and resources, but this should be an aspiration across all branches of medicine. Medicine ignores social factors in order to be seen as science based, but it needs to be emphasized that medicine is art backed by science. Understanding social aspects of medicine in causation, precipitation, and perpetuation of distress is critical. Multifaceted responses and social causations in the context of social determinants in the clinical practice as well as research need to be undertaken as a matter of urgency irrespective of specialty within medicine.

Going back to Anna Karenina, unhappy families because of illnesses and distress and sickness have stories to tell which we as clinicians need to hear and learn about so that we can place the patient in the context of their social environment. Therefore, as mentioned above, individual and individual family's response to the same set of symptoms, the same diagnosis, and the same treatment are different because they are responding in different social manner. Social status, educational and economic status, and other factors will mold these responses. It can be argued that response to the same physical treatment in different individuals can be influenced by social factors. Embedded within the doctor–patient relationship is the implicit social contract between society and medicine which raises another social dimension to the relationship.

Medicine's implicit social contract with the society often gets forgotten perhaps because the contract is implicit and not explicit. There is no doubt that the society expects from the medical practitioners: competency in their chosen field, with certain ethical and moral imperatives and values with openness, transparency, and probity embedded within the role of a healer. In addition, physicians are and should be the source of impartial advice and demonstrate altruistic values. With changes as a result of access to social media, it is even more important that the profession remains the main source of impartial advice. On the other hand, physicians expect not only autonomy but also a degree of trust supported by adequate resources and financial or social recognition for their clinical commitments and what they do. There is no doubt that surveys consistently show doctors to be probably the most trusted group. There is a reason for that which is to do with altruism, professional values, and other aspects embedded in the role.

Over the past 3–4 decades, medicine has become much more technical and mechanical with a large number of investigative and interventional techniques affecting humanity of doctors in their relationship with the patients. Furthermore, in many countries, medicine has become much more defensive and extremely risk aversive where doctors tend to investigate more often and vigorously. Thus, such rapid advances in technological aspects of medicine continue to add to the costs of health-care delivery and consequently demand for newer and safer treatments increases. The potential for payment for these interventions and investigations means increased burden on society and populations. Furthermore, as society continues to evolve and fragment with globalization and urbanization, thereby increasing expectations, but it is not clear who the representatives of the society are with whom the profession should work. In addition, as the society evolves and with generational changes, social expectations and social roles change and doctors may not always be cognizant of that. Therefore, understanding the impact of social factors on etiology and management of medical disorders is critical in not only providing better care through improved relationship but also bringing humanity and empathy back into medicine.

In the first quarter of the 21st century, on the one hand, societies have changed at a rapid pace due to globalization, rapid industrialization, and urbanization, and on the other hand, the younger generation of doctors and patients carries a very different set of attitudes to technology and expectations of therapeutic encounters. The social responsibilities of psychiatry and medicine are multifaceted. Prevention and health promotion are one but understanding the impact of social factors on the causation of disease and influencing the development of interventions which can work on individuals, families, and societies are equally important.[28]

Hence, understanding social factors within which our patients live, work, and play are crucial in delivering care which patients and their carers will accept is crucial. In this direction, other medical schools need to follow the example of Harvard Medical School which has been running Introduction to Social Medicine and Global Health course for 1st-year students since 2007.[29]

For prevention of physical as well as psychiatric disorders, our understanding and application of social interventions are critical. This needs to be incorporated from an early stage of medical undergraduate curriculum with emphasis on the social factors on the one hand and the relationship between society and medicine on the other, both of which will enable a shift from the cult of technology to more humane, holistic, and humanistic medicine. This will then support our role in better advocacy for our patients, which remains an area of high priority.

Social determinants of health apply to many medical conditions and specialties. Social inequalities and increasing social disparity call for a loud clarion call by the profession. Even medicine is not a pure science, so this false dichotomy between technological science and humanity-guided science needs to be abandoned. Medicine must speak up loudly and clearly for its patients and their needs, to take its role and responsibility in public health and advocacy more seriously and vigorously and highlight the impact of social inequalities and resulting inequalities as a result of illness. The profession needs to acknowledge the importance of social aspects of medicine and its sequelae but equally importantly speak for and advocate for those who are most vulnerable and may not have a voice or may not be heard.

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