SM750: Introduction to Social Medicine and Global HealthHarvard Medical School, Fall 2013

Paul Farmer, David Jones, and Jen Kasper, Course Directors

Social, economic, and political forces powerfully influence who gets sick, what diseases afflict them, which treatments are available, and the outcomes of those treatments. Why else does heart disease persist as the world’s leading cause of death, even though the measures needed to prevent it have been known for over fifty years? Why else are outcomes of HIV infection so different in different countries, and why do they vary widely even within the United States?

All physicians encounter such questions in their clinical work, whether they work in Boston, elsewhere in the United States or further afield. These questions cannot be answered by studying molecular biology and pathophysiology alone. Medical education and practice must be grounded in an understanding of social medicine, a field of inquiry that uses the methods of the social sciences and the humanities to analyze disease and medicine.

This course will introduce students to the theory and practice of social medicine to enable them to recognize these forces wherever they work, to understand how they affect their patients, and to develop appropriate responses. Lectures and tutorials will explore (1) the determinants of disease and health inequalities between populations and over time; (2) how social factors influence medical knowledge and health care; and (3) what must be done to combat and prevent health inequalities in local, national,

and global contexts. We will emphasize the continuities between local and global, showing how insights gained in one setting can often be applied and adapted in many others. This course will provide a space where different perspectives can be debated, using available evidence, to understand what we can do to optimize the health and well-being of people in the United States and around the world.

Course Schedule

09/05 Lecture: What Is Social Medicine? Course DirectorsTutorial: Case – The Challenge of Medicine

09/12 Lecture: The Burden of Disease David JonesTutorial: Case – Health Measures and Priorities

09/19 Lecture: What Is Race? David JonesTutorial: The Social Determinants of Disease

09/26 Lecture: Health and Wealth Jen KasperTutorial: The Problem of Poverty

10/03 Lecture: Disease and Responsibility Allan BrandtTutorial: Does Responsibility Matter?

10/10 Panel: Increasing Value in Health Care Michael Porter & Thomas Lee

10/17 Lecture: The Anatomy of Evidence-Based Medicine (Amp D) Jerry Avorn

Tutorial: Conflicts of Interest

10/24 Tutorial: Caring for Complex PatientsLecture: Taking Medicine Beyond the Clinic -- PACT Heidi Behforouz

10/31 Lecture: What Is an Effective Treatment? David JonesTutorial: How Patients Experience Efficacy

11/07 Lecture: Taking Medicine Beyond the Clinic -- MLP Megan SandelTutorial: ***

11/14 Lecture: From Knowledge to Policy – MDR-TB Carole MitnickPanel: Global Health Strategy Global Health Faculty

11/21 Lecture: Disparities in Treatment Access and Outcome David JonesTutorial: Disparities by Race and Place

12/05 Lecture: Violence Anne Becker & Eric FleeglerTutorial: Social Medicine and Politics

12/12 Lecture: Health Initiatives in the 21st Century Paul FarmerLecture: Social Medicine and Structural Competence Course Directors

Course Summary and Learning Objectives

This course introduces students to social medicine, a field that applies social science to improve clinical care. Social medicine occupies a middle ground between most other medical disciplines (which apply basic and clinical science to clinical care) and public health (which applies basic and social science to population health). Lectures will define and illustrate key concepts. Tutorial will allow students to explore questions where consensus does not exist so that they understand both the ambiguities in medical theory and practice and the stakes of their decisions. In two of the weeks we will bring in outside guests and meet as a whole class for the two hour session. The goal throughout is to define the challenges faced by physicians in pursuit of optimal outcomes for their patients, offer valuable perspective gleaned from the social sciences, and discuss pragmatic solutions to the problems. This course will help you understand the disease and treatment experiences of your patients whether you work in Boston, elsewhere in the United States, or in other global settings.

Each week a study guide will define learning objectives, introduce the readings, and present illustrative clinical vignettes. Most weeks there will be a brief questionnaire that you will fill out on-line and a short writing assignment. Both the questionnaire and the assignment should be completed before noon on Wednesday.

By the end of this course, students should be able to:

• Recognize the potential contributions of social science to clinical care, including history, anthropology, sociology, epidemiology, demography, economics, and geography.

• Understand certain key concepts in medicine, in particular how they can be conceptualized differently (and more productively) when seen from the perspective of social medicine.

• Appreciate the major obstacles that stand between physicians and optimal health outcomes.

• Understand the importance of considering patients’ social worlds, both when thinking about the causes and distribution of disease, and when designing solutions to health care problems.

• Develop a tool kit of possible solutions, with an appreciation of their strengths and limitations. These will serve as models as you develop your own solutions for the challenges you encounter in clinical practice.

If you have to miss any of the sessions, please notify your tutor in advance.

Key Concepts

social medicinehealth care deliveryburden of diseasedefining diseasesetting health care prioritieshealth disparities / health inequalitiessocial determinants of diseasesocial geography of diseasestructural violenceembodimentbiosocial analysispovertysocioeconomic statuslivable wagemedical bankruptcymorality and diseaseresponsibility for diseaseresponsibility for treatment outcomesvalue in health caremeasurement of health care outcomesproduction, circulation, and consumption of medical knowledgeconflicts of interesttherapeutic systemefficacy and effectivenessmagic bullets (and the limits of reductionism)role of medicinenon-compliance and non-adherencesocial strategy -- knowledge base -- political willimmodest claims of causalityaccompanimentadvocacyteamwork, professionalism, and inter-professionalismhealth literacy (and its limits)agency, constraint, and empowermentmedicine vs. public healthdifference and disparity: race, sex, genderinternational health, global health, one healthglobalization and global social changeimplementation and accesscultural competencestructural competence

What Is Social Medicine?ISM 2013: September 5th, 1:30-3:30

Overview:Some medical students have an optimistic vision of their future jobs: patients come to clinics with a chief complaint; doctors diagnose the problem and prescribe treatment; patients follow through on the treatment and get better. Actual clinical care is rarely this simple. Even when the diagnosis is clear and good treatment exists, patients do not achieve the desired health outcome. This course will help you to understand why, and to strategize about solutions. A brief lecture will introduce the concept of social medicine and the structure and content of the course. The tutorial discussion will focus on the experience of a boy from Roxbury with asthma as a springboard for brainstorming about the sorts of obstacles that can make good clinical outcomes so hard to achieve. Santiago’s experiences illustrate the themes that we will explore in the course and demonstrate how social medicine can contribute to clinical care.

Key Concepts:social medicinehealth care delivery

Case:Santiago is an 8-year old boy who comes to your pediatric clinic for follow up after an ED visit the night before. His mother, Carmen, had taken him to the hospital last night because of respiratory distress -- his 8th serious asthma flare this year, two of which required hospitalization. Frequent ED visits are usually preventable with adequate asthma management. What obstacles might be contributing to Santiago’s poor outcome?

Optional Background Readings:Porter, Dorothy. “How Did Social Medicine Evolve, and Where Is It Heading?”

PLoS Medicine 10 (October 2006): 1667-1672. This historical review traces the development of social medicine from its 19th century origins through its 20th century forms (e.g., the contrast between social medicine in the US/UK and in Latin America).

Kenyon, Chén, Megan Sandel, Michael Silverstein, Alefiya Shakir, and Barry Zuckerman. “Revisiting the Social History for Child Health.” Pediatrics 120 (2007): e734-e738. In Patient-Doctor I you will learn how to take a history from patients. One oft-neglected piece of this is the “social history.” Motivated by the problem of pediatric asthma, this article explains why a thorough social history is essential to good medical care.

Tough, Paul. “The Poverty Clinic: Can a Stressful Childhood Make You a Sick Adult?” New Yorker, 21 March 2011, pp. 25-32. This essay describes the efforts of one young doctor to provide excellent care for her patients in San Francisco. Pay attention to the links between social worlds and disease. How does she structure her practice in response?

Sandel, Megan, and Joshua Sharfstein. “Not Safe at Home: How America’s Housing Crisis Threatens the Health of Its Children.” Doc4Kids Project, Boston Medical Center, February 1998. Two residents at Boston Medical Center studied the impact of housing conditions on health (e.g., asthma, pp. 8-9). What can doctors do -- as individuals, team members, and advocates -- to treat the root causes of disease (pp. 19020)?

Hendeles, Leslie, Gene L. Colice, and Robert J. Meyer. “Withdrawal of Albuterol Inhalers Containing Chlorofluorocarbon Propellants.” New England Journal of Medicine 356 (29 March 2007): 1344-1351. Metered dose inhalers (used widely for asthma) used to rely on CFC propellants. Because of concern with ozone depletion, the FDA mandated that they be replaced with new propellants, something that increased patients’ medication costs. How should competing health interests be weighed? Was this good policy?

Harrison, Emily. “Change In the Air.” Scientific American 299 (August 2008): 20-22. This commentary on the ozone-albuterol decision describes the economic and political interests in play. The author is now a grad student in History of Science at Harvard.

Learning Objectives:1. Understand how social medicine can contribute to clinical care by

recognizing how social, economic, and political forces influence who gets sick, what diseases afflict them, which treatments are available to them, and the outcomes of those treatments.

2. Begin to see how anthropology, sociology, history, and other social sciences and humanities offer analytical frameworks for understanding these processes. What do you need to know to be a good doctor for your patients?

3. Brainstorm about the obstacles to optimal treatment in Boston.4. Apply the insights of social medicine to develop solutions that could

improve the delivery of health care on local, national, and global scales.

5. Recognize opportunities for advocacy on behalf of patients and for intervening to improve the structures of health and health care delivery.

The Burden of DiseaseISM 2013: September 12th, 1:30-3:30

Overview:Medicine seeks to prevent, treat, or palliate the suffering caused by disease. As you set out to become doctors, it is helpful to have a sense of exactly what burden of disease you will face. Even this seemingly simple question is actually quite difficult. It is not always easy to define what is or is not a disease. Once a provisional definition is in hand, there are many ways that the burden of disease can be measured, and different measures have radically different consequences for health policy. Lecture will introduce a series of different ways of measuring the burden of disease and discuss some of the pros and cons of each. In tutorial you will brainstorm about which measures are most useful for setting the agenda for medicine. How might the answers differ from the perspective of a primary care provider, clinic director, state planner, or federal funding agency?

Key Concepts:defining diseaseburden of diseasesetting health care priorities

Cases:1. You are put in charge of a struggling community health center with a mandate to revamp its staffing to make it more responsive to community needs. A consultant provides you with several measures of the burden of disease in the community: (a) most common chief complaints at clinic visits; (b) most common causes of hospital admissions from your practice; (c) health care expenditures at the clinic; (d) leading causes of disability in the community; (e) leading causes of death in the community. What health problems should you prioritize as you design a staffing model for your clinic?

2. The Governor asks you to serve as Secretary of Health and Human Services with a budget of $16B. Instead of maintaining the spending status quo, you want the Commonwealth’s health spending to reflect and manage the burden of disease. Which of the various measures (outpatient visits, admissions, expenditures, disability, deaths), should you prioritize?

3. You are hired as a consultant to the Ministry of Health in India. The annual health expenditure per capita (public and private) is $59 (vs. $8608 in the United States). You review the Global Burden of Disease Visualizations and see quite different rankings for DALYs, Deaths, YLLs, and YLDs. How would you prioritize health care resources -- on what diseases, and on what segments of the population?

4. The President nominates you to direct the National Institutes of Health with a budget of $31B to spend on biomedical research. Should you allocate funding according to the burden of disease (and if so, which measure), in response to advocacy by politicians and patients groups, or according to predictions of which research will have the greatest scientific value?

Readings:Jones, D.S., Scott H. Podolsky, and Jeremy A. Greene. “The Burden of

Disease and the Changing Task of Medicine.” New England Journal of Medicine 366 (21 June 2012): 2333-2338. This short essay introduces the concept of the burden of disease and some of the questions raised by its definitions and changing patterns over time.

Murray, Christopher J.L., and Alan D. Lopez. “Measuring the Global Burden of Disease.” New England Journal of Medicine 369 (1 August 2013): 448-457. This is the most recent report from WHO’s Global Burden of Disease Project. They have a cool visualizations available at: http://www.healthmetricsandevaluation.org/gbd/visualizations/country

Gross, Cary P., Gerard F. Anderson, and Neil R. Powe. “The Relation Between Funding by the National Institutes of Health and the Burden of Disease.” New England Journal of Medicine 340 (17 June 1999): 1881-1887. How should NIH set its research priorities? This piece reviews the relation (or not) between various measures and actual funding. What factors, beyond the burden of disease do (and should) influence policy?

Different Measures of the Burden of Disease [various sources]. This collection contains different representations of the burden of disease. Pay attention to which diseases rise and fall in importance according to the different measures.

Boston Public Health Commission. Health of Boston 2012-2013: A Neighborhood Focus. Boston: Boston Public Health Commission, Research Office, 2013. Every year the BPHC updates this report on health conditions in Boston. What health conditions (and root causes) receive the most attention (e.g., pp. 8-18)? How is burden of disease measured? Other sections will be useful for the assignment due 9/19.

Learning Objectives:1. Learn some of the different measures used to catalog disease in

individuals and populations and recognize the pros and cons of each.2. Understand implications that different measures of the burden of disease

have for medicine and health policy.3. Appreciate how patterns of disease vary over time and between different

populations, and how health inequalities have persisted as the burden of disease has changed. A good account of disease pathophysiology must be able to account for these patterns.

4. Imagine systems of medicine and public health that might best eclipse the burden of disease.

Questionnaire:Please complete the questionnaire about the case vignettes before noon on

Wednesday.

Writing Assignment:Take the position of one of the people in the case vignettes (clinic director, Secretary of HHS, consultant to India MoH, Director of NIH) and explain which measure (or measures) of the burden of disease (present or future) would be most important for you as you set your policy agenda. Please limit your answer to 500 words or fewer; email it to your tutor before noon on Wednesday.

Questionnaire (9/12):

Case 1: What problems would you prioritize as you design a staffing model for your clinic:(a) most common chief complaints at clinic visits(b) most common causes of hospital admissions from your clinic(c) leading causes of health expenditures at your clinic(d) leading causes of disability in the community(e) leading causes of death in the community

Case 2: What problems would you prioritize as you allocate the HHS budget:(a) most common chief complaints at clinic visits throughout Massachusetts(b) most common causes of hospital admissions at Massachusetts hospitals(c) leading causes of health expenditures in Massachusetts(d) leading causes of disability in Massachusetts(e) leading causes of death in Massachusetts

Case 3: What would you advise the Ministry of Health to focus on:(a) deaths(b) years of life lost(c) years lived with disability(d) disability adjusted life years

Case 4: Which of the following criteria should be given the most weight in determining the allocation of NIH research funds?(a) public health needs (e.g., measures of the burden of disease)(b) scientific quality of the proposed research(c) probability of a successful research outcome(d) maintenance of a diverse portfolio of funded research(e) maintenance of an adequate scientific infrastructure

The Social Determinants of DiseaseISM 2013: September 19th, 1:30-3:30

Overview:At Harvard Medical School you will learn an immense amount about the pathophysiology of disease, focusing on organs, tissues, cells, and molecules. This knowledge is essential to medical care. However, this reductionist approach to disease leaves key aspects unaddressed. Why has obesity doubled in the United States over the past generation? What accounts for the global distribution of HIV? The answers to these questions cannot be found in molecular biology. Instead, to answer the most basic questions about the local, national, and global distribution of disease, you must understand the social determinants of disease. This knowledge provides the foundation for any attempt at a comprehensive health care policy. In lecture, we will examine one specific determinant, race, and offer a provisional account of how race reveals the complex interactions between society and biology. In tutorial we will examine health inequalities in Boston, try to understand possible social determinants, and imagine possible interventions or solutions.

Key Concepts:health disparities / health inequalitiessocial determinants of disease (and the social geography of disease)structural violenceembodimentbiosociallimits of reductionism

Case:The Health of Boston 2011 contains maps of many health inequalities (e.g., p. 366, obesity rates vary between 7% and 37%; p. 372, heart disease hospitalizations vary between 13.6 and 30.3 / 1000 residents). We have also posted disparity charts from earlier editions of HoB. The most recent edition (2012-2013), interestingly, drops these neighborhood comparisons. Pick a health inequality that interests you and generate hypotheses about its possible causes, focusing on two neighborhoods with divergent rates. Then go on a walking tour of those neighborhoods and see if you can learn anything that offers clues to the disparities. It is best to work in groups on this assignment. You can pick any health inequality, but be sure to pick one for which relevant factors might be observable. Don’t be shy about talking with clerks at convenience stores, staff members at neighborhood clinics or social service agencies, etc. For instance, if you see a crew at a fire station, ask what kind of emergency calls they get and what they see in people’s homes. Look for both liabilities (e.g., degraded infrastructure; limited access

to healthy foods; lack of opportunities for walking or exercise) and assets (clinics, social service agencies, diverse food offerings, evidence of social capital) in the community. Health of Boston 2012-2013 offers good descriptions of each neighborhood. We have also posted a guide to some of the neighborhoods, produced by the Harvard College Freshman Urban Program.

Readings:Marmot, Michael. “Health in an Unequal World.” Lancet 368 (9 December

2006): 2081-2094. A physician and epidemiologist, Marmot chaired the WHO commission on social determinants of health. What social gradients are most striking? How can they be explained? How should societies respond to evidence that social structures influence human health?

Link, Bruce G., and Jo Phelan. “Social Conditions As Fundamental Causes of Disease.” Journal of Health and Social Behavior 35 (1995): 80-94. In this classic article, Link and Phelan argue that physicians and epidemiologists need to spend less time studying proximate risk factors and more time studying fundamental causes. What puts people at risk of risks (p. 85)?

Krieger, Nancy. “Genders, Sexes, and Health: What Are the Connections – and Why Does It Matter?” International Journal of Epidemiology 32 (2003): 652-657. Krieger, a prominent theorist at the HSPH explores the inconsistent definitions of sex and gender. Focus on her twelve examples of how gender relations and sex-linked biology interact to create disparities in health and disease.

Kuzawa, Christopher W., and Elizabeth Sweet. “Epigenetics and the Embodiment of Race: Developmental Origins of US Racial Disparities in Cardiovascular Health.” American Journal of Human Biology 21 (2009): 2-15. Discussions of race, biology, and inequality have long been controversial and politicized in the United States. How do social forces become internalized through molecular mechanisms?

Learning Objectives:1. Appreciate how knowledge of a community can enhance your ability to

provide care to people from that community. How much do you need to know to be a good doctor?

2. Understand the key theories and findings from the literature on the social determinants of disease, from broad claims about the influence of social, economic, and political forces, to the molecular pathways that underlie the processes of embodiment.

3. Recognize why doctors have often sought to work beyond the clinic and hospital in order to improve the health of their patients.

4. Understand how the links between the distributions of wealth and power and the distribution of disease inevitably lead to the politicization of

health and health care. How can physicians best navigate their politicized terrain?

5. Recognize the obstacles to providing decisive explanations of the patterns of health inequalities? What are the implications for clinical care and advocacy?

Questionnaire: none this week

Writing Assignment:Once you have completed your walking tour, revise your hypotheses in light of what you learned. Write up an account of your findings (500 words max) and submit them to your tutor by noon on Wednesday. We don’t expect you to find a “right answer” that explains any of these disparities. Instead, we are looking for thoughtful discussions of what sorts of factors might contribute to the inequalities seen in particular diseases. You should submit one report per group; if your group has students from more than one tutorial, send the report (listing all of the students involved) to each of the relevant tutors.

Wealth and HealthISM 2013: September 26th, 1:30-3:30

Overview:According to a 2013 report from the US Census Bureau, 22 percent of households experienced one or more hardships in fulfilling their basic needs in the previous 12 months (e.g. difficulty meeting essential expenses, not paying rent or mortgage, getting evicted, not paying utilities, having utilities or phone service cut off, not seeing a doctor or dentist when needed, not always having enough food). Why is this kind of poverty a problem for doctors? Poor people -- both children and adults -- have less access and use of preventive health strategies, less access to timely and appropriate health care and treatments, and worse health outcomes than their wealthier counterparts. This is not simply a question of “the poor” versus “the not poor”: there is a gradient of worsening health outcomes that follows the gradient in socioeconomic status, with the “working poor” or “near poor” suffering health consequences. Moreover, the risk of being poor (and suffering the resultant health consequences) in the United States follows predictable patterns of geography, race/ethnicity, gender, and education. What can doctors do about this? Lecture will reveal the nature of poverty in the US (changing definitions, demographics, the politics of personal responsibility, etc.) with a focus on child poverty; global perspectives on poverty; and the mechanisms that link poverty to health outcomes. It will also describe some of the public assistance programs available in the US and the myriad ways that physicians can intervene in order to improve health outcomes for their patients.

Key Concepts:Poverty guidelines vs. poverty thresholds vs. median incomePoor, near poor, working poorMinimum wage vs. livable wagePoverty-reduction strategies

Cases:No new cases this week -- but think back over your walking tours and consider to what extent poverty was a root cause of the disparities you were examining, how poverty generates adverse health outcomes, and what options exist for doctors and medicine to contribute to a solution.

Readings:Braveman, Paul A., Catherine Cubbin, Susan Egerter, David R. Williams, and

Elsie Pamuk. “Socieoconmic Disparities in Health in the United States: What the Patterns Tell Us.” American Journal of Public Health 100 (September 2010): S186-196.

O’Toole, Thomas, Jose J. Arbelaez, Robert S. Lawrence, and the Baltimore Community Health Consortium. “Medical Debt and Aggressive Debt

Restitution Practices: Predatory Billing among the Urban Poor.” Journal of General Internal Medicine 19 (July 2004): 772-778.

McCally, Michael, Andrew Haines, Oliver Fein, Whitney Addington, Robert S. Lawrence, adn Christine K. Cassel. “Poverty and Ill Health: Physicians Can, and Should, Make a Difference.” Annals of Internal Medicine 129 (November1998): 726-733.

Alsan, Marcella M., Michael Westerhaus, Michael Herce, Koji Nakashima, and Paul E. Farmer. “Poverty, Global Health and Infectious Disease: Lessons from Haiti and Rwanda.” Infectious Disease Clinics of North America 25 (September 2011): 611-622.

Learning Objectives:1. Understand the bidirectional relationship between poverty and health and

the complex links between them.2. Recognize the importance of including a thorough social history (e.g.

income, education, immigration status) when interviewing patients to gain an understanding of the social determinants that potentially affect their health.

3. Debate the role of the physician in caring for patients who are poor and provide examples of successful interventions.

Questionnaire:None this week.

Writing Assignment:Please choose one of the following and write a 500-word discussion, incorporating the course readings, and send it to your tutor before noon on Wednesday. 1. Interview someone (e.g. friend, family member, patient from PD1) about their economic situation and the economic consequences of their illness (e.g. co-pays, out of pocket expenses, job loss, paying for rent, food, utilities). What is the most pressing economic consequence that this person faces and how might you as a physician help them address it?

2. Imagine you are a physician 8 to 10 years from in Boston working with a typical patient population in which roughly 30% of your patients are poor. Choose one of the social service agencies listed in the ISM resources for this week (or hunt around on your own for other agencies in the greater Boston area). Read their mission statement and their areas of focus/activities. How might this agency’s services help you to optimize the health of your patients?

3. A unique aspect of the Cuban health care system is that there is approximately one doctor for every 100 people, and the doctor lives and cares for the people in his/her community. Health care in the United States is staffed very differently. Review the two areas of Boston you chose for

your walk. Find data (e.g. the Boston Public Health Commission Report) that describes relevant social variables: percent below the poverty level; proportion living in substandard (e.g., low-income / section 8) housing; prevalence of food insecurity; ethnic composition and immigration status; education; employment; or any of the other social determinants that we have discussed so far. Describe some of the social service agencies available in those two communities -- the resource provided in this week’s materials contain some examples. If you were the doctor living in one of those two communities, what social determinants would you prioritize and why?

Looking ahead: There will be weekly writing assignments most weeks in this course. You also have an option of doing a final project of your own choice in place of the final four weekly assignments (weeks of 11/14, 11/21, 12/5, 12/12). Details will follow later, but keep this in the back of your mind if you come across topics that you would like to examine in more detail.

Disease and ResponsibilityISM 2013: October 3th, 1:30-3:30

Overview:Who is responsible for disease, especially in an era when so much of the burden of disease is linked to lifestyle (diet, physical activity, and cigarettes)? Should responsibility for a disease have consequences? Whatever you think is the right answer to these questions, it is likely that during your career you will have intuitions about these questions and judge patients based on your assessment of their responsibility. While it is simple to say that “it is wrong (or not helpful) to judge patients in this way,” a subtler assessment is necessary. Thinking about responsibility is an essential part of understanding the causes of disease, especially in a world where social determinants are prominent. And there are times when holding a patient responsible can be pragmatic and productive. How can you tell when it is appropriate? Lecture and two of the readings examine one area where responsibility has been examined in great detail: cigarette smoking and the diseases that result from it. The cases present a series of other cases in which patients are held responsible for their health behaviors or diseases in different ways. Next month we will take up a related question: non-compliance, accountable care, and responsibility for treatment outcomes. We do not expect that you will have clear answers here. Instead, we want to get you thinking about an important set of questions of medical practice and health policy that will challenge you throughout your careers as physicians.

Key Concepts:morality and diseaseresponsibility for disease

Cases:1. A health insurer decides to impose higher premiums for people who have pre-existing medical conditions (e.g., cardiovascular disease, pregnancy, multiple sclerosis, Hepatitis C, diabetes, etc.) when they enroll. This will not be allowed as of 2014 under the Accountable Care Act.

2. A health insurer reviews is actuarial data and recognizes that certain behaviors are associated with increased health care spending. Some of the high risk activities include: overweight; contact sports; serving in the military reserves; hunting; unprotected sex with multiple partners; cigarette smoking; surgeons who operate on patients with high rates of HCV, HBV, and HIV; motorcycle riding; bicycle riding in urban areas; physicians who work in developing countries.

3. An employer decides that it will no longer hire new workers who are smokers. It bans smoking in all of its buildings and property to make it difficult for active smokers to continue smoking.

4. An employer decides that it will no longer hire new workers who have a BMI > 25.

5. An internist with a busy practice decides that he will no longer see patients who continue to smoke actively.

6. A cardiologist with a busy practice decides that she will no longer see patients who continue to smoke actively.

7. The liver transplant team at a hospital decides that it will no longer perform liver transplants on patients who drink alcohol; patients must demonstrate six months of abstinence before they can be listed for transplant.

8. An overweight patient, with a strong family history of obesity, asks his physician to reassure him that obesity is not his fault because he is genetically predisposed to the disease.

9. One of your patients suffers from back pain. The pain does not seem to be particularly severe, but the patient reports that it causes her to miss so many days at work that she has lost her job. She asks you to support her application for Social Security disability benefits.

Readings:Knowles, John H. “The Responsibility of the Individual.” Daedalus 106

(1977): 57-80. Knowles was medical director of MGH from 1962 to 1971 and then president of the Rockefeller Foundation until his death in 1979. He argues that patients have a moral obligation to preserve their health. Many students dismiss Knowles as dated or punitive. But read carefully -- his arguments about responsibility are actually quite subtle (e.g., what is the role of governments)? For a recent (and less nuanced) example of this argument, see the 2009 Wall Street Journal editorial by the founder of Whole Foods, available at http://online.wsj.com/article/SB10001424052970204251404574342170072865070.html

Brandt, Allan M. “The Cigarette, Risk, and American Culture.” Daedalus 119 (Fall 1990): 155-176. Brandt examines the debates about cigarettes and lung cancer, a domain in which changing attitudes toward risk have played out dramatically.

Brandt, Allan M. “Globalization: Exporting an Epidemic.” In The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America. New York: Basic Books, 2007. pp. 449-492. Here

Brandt traces how tobacco companies responded to increasing litigation and regulation within the United States by focusing their efforts on global markets. Is the federal government, which forced foreign countries to open their markets to American tobacco, responsible for diseases that develop there?

Learning Objectives:1. Understand how responsibility for disease can be assigned in many places,

from individual patients to their social, economic, and political contexts.

2. Recognize that assignment of responsibility has powerful consequences for how diseases are managed, resources are mobilized, and diseases are stigmatized.

3. Begin to decide whether it is ever useful, for physicians to take responsibility into consideration in their work.

Questionnaire:Please complete the questionnaire about the case vignettes before noon on

Wednesday.

Writing Assignment:Please write a 500 word response to one of the following prompts. Please email your response to your tutor before noon on Wednesday.

1. Do you accept Knowles’s argument that there is a “moral obligation to preserve one’s health--a public duty”? Why or why not?

2. Brandt suggests that the federal government is partly responsible for the prevalence of smoking (and lung cancer) in the United States and overseas? Do you agree? Be sure you make a clear argument for or against this position.

3. As you accumulate more experience in medicine (e.g., through your other courses, Patient-Doctor, shadowing experiences, etc.), you can use a weekly writing assignments as an opportunity for reflection. Have you experienced something interesting, for which social medicine (or one of the readings) offers a valuable perspective?

Questionnaire (10/03): Disease and Responsibility

Case 1. A health insurer decides to impose higher premiums for people who have pre-existing medical conditions (e.g., cardiovascular disease, pregnancy, multiple sclerosis, Hepatitis C, diabetes, etc.) when they enroll. This will not be allowed as of 2014 under the Accountable Care Act. Is it appropriate, from the perspective of the insurer, to charge higher premiums for people with pre-existing conditions?(a) yes(b) no

Case I: Is it appropriate, from the perspective of society, for insurers to charge higher premiums for people with pre-existing conditions?(a) yes(b) no

Case 2. A health insurer reviews is actuarial data and recognizes that certain behaviors are associated with increased health care spending. Some of the high risk activities include: overweight; contact sports; serving in the military reserves; hunting; unprotected sex with multiple partners; cigarette smoking; surgeons who operate on patients with high rates of HCV, HBV, and HIV; motorcycle riding; bicycle riding in urban areas; physicians who work in developing countries. Would it be appropriate for the insurer to add a surcharge / penalty to the premiums of people who engage in high risk activities?(a) yes(b) no

Case 2: Would it be appropriate for the insurer to provide rebates for people who avoid high risk activities?(a) yes(b) no

Case 2: Would it be appropriate for the insurer to provide rebates to people who engage in high risk activities if they give them up?(a) yes(b) no

Case 3. An employer decides that it will no longer hire new workers who are smokers. It bans smoking in all of its buildings and property to make it difficult for active smokers to continue smoking. Is this an appropriate policy?(a) yes(b) no

Case 4. An employer decides that it will no longer hire new workers who have a BMI > 25. Is this an appropriate policy?(a) yes(b) no

Case 5. An internist with a busy practice decides that he will no longer see patients who continue to smoke actively. Should the clinic director allow the internist to limit his practice in this way?(a) yes(b) no

Case 6. A cardiologist with a busy practice decides that she will no longer see patients who continue to smoke actively. Should the department chair allow the cardiologist to limit her practice in this way?(a) yes(b) no

Case 7. The liver transplant team at a hospital decides that it will no longer perform liver transplants on patients who drink alcohol; patients must demonstrate six months of abstinence before they can be listed for transplant. Which of the following answers best reflects your opinion of the new transplant policy?(a) it is not appropriate to make access to transplant contingent on abstinence(b) it is appropriate, because patients who damaged their liver through alcohol use should not be eligible for a transplant(c) it is appropriate, because people who use alcohol after a transplant are at risk of bad outcomes (e.g., because of damage to the new liver or non-compliance with immunosuppressive drugs)(d) both B and C

Case 8. An overweight patient, with a strong family history of obesity, asks his physician to reassure him that obesity is not his fault because he is genetically predisposed to the disease. As his physician, would you reassure him that the obesity is not his fault?(a) yes(b) no

Case 9. One of your patients suffers from back pain. The pain does not seem to be particularly severe, but the patient reports that it causes her to miss so many days at work that she has lost her job. She asks you to support her application for Social Security disability benefits. Would you be willing to sign the patient’s application for disability because of her back pain?(a) yes(b) no

Value in Health CareISM 2013: October 10th, 1:30-3:30

Overview:This course began by introducing two key concepts: the burden of disease and the social determinants of disease. Knowledge of disease and its causes defines that challenge faced by medicine. The remainder of the course examines how we can best respond to this challenge. We will start this week with a fundamental question: what is value in health care? This might seem like a trivial question -- doctors want to cure patients. In practice it is much subtler. Insights from business offer a more precise definition of value and allow physicians to examine whether their health care systems are designed to provide value. To explore this material we have invited two experts who struggle with this question every day. Michael Porter is the pre-eminent theorist of business strategy at Harvard Business School; for the past decade he has focused on what he considers the most dysfunctional and challenging of all industries: health care. Thomas Lee, a cardiologist, directed clinical operations for Partners Healthcare for many years and is now chief medical officer of Press Ganey (a company hired by most health care providers to measure patient-perceived health care quality). We will meet as a group for the full two hours. Professor Porter and Dr. Lee will offer their own perspectives on value and launch a discussion of current challenges in health care delivery.

Key Concepts:value in health carehealth care deliverymeasurement of health care outcomesintegrated care deliverybundled payments

Cases: none

Readings:Porter, Michael E., and Thomas H. Lee. “The Strategy That Will Fix Health

Care.” Harvard Business Review (October 2013): 1-19. Approaching medicine from the perspectives of business strategy and health care delivery, Porter and Lee describe their vision for medicine, a fundamental restructuring of medicine in pursuit of value-based care. Do their proposed reforms make sense? What forms of resistance will this vision encounter from doctors, hospitals, and other interests? How could insights from social medicine enhance their models?

Porter, Michael E., and Thomas H. Lee. “Why Health Care Is Stuck -- And How to Fix It.” HBR Blog Network, 17 September 2013. In this companion piece, Porter and Lee explain the structural forces that have produced our current, misaligned health care system.

Gawande, Atul. “The Bell Curve: What Happens When Patients Find Out How Good Their Doctors Really Are?” New Yorker (24 December 2004). Gawande examine what happens when clinics take quality analysis and improvement seriously. Would you like to be a clinician in Cincinnati Children’s Hospital’s “Openness Initiative”? Again, how could social medicine be relevant here?

Berwick, Donald W. “To Isaiah.” JAMA 307 (27 June 2012): 2597-2599. Berwick, back in Boston from an 18-month stint in charge of Medicare, gave this talk as the commencement address at HMS. How does he define value in health care?

Learning Objectives:1. The health care system in the United States is expensive, disorganized,

inefficient, and inadequately successful at improving the health of our population. Understand why we have ended up with this situation.

2. Recognize how health care systems would differ if they focused on improving value and not on controlling costs.

3. Understand why physicians must take the lead in restructuring systems of health care delivery. A first step towards that is careful measurement of treatment outcomes. This will require major cultural and structural changes in health care.

4. Recognize how the insights of social medicine can inform debates on the organization and delivery of health care.

Questionnaire: none this week

Writing Assignment:Before noon on Wednesday, please write a 500 word response to one of the following sets of questions based on the readings. You don’t need to answer every aspect of the prompt -- answer what interests or vexes you. Think in terms of the key issues in social medicine.

1. Some health care reformers argue that there needs to be more transparency in health outcomes data. Specifically, doctors, clinics, and hospitals should be ranked according to the outcomes they achieve, and this data should be freely available to all perspective patients. Do you, as future doctors, support this? Will you want to know where on the bell curve you are? What would be accomplished my implementing this reform? What problems does it face? Would the data reveal who is or is not a good doctor?

What other data would be needed? Would patients be able to use this data to good effect? What aspects of professional authority and prestige would be challenged?

2. Many health care reformers want to move towards a system of bundled payments. One impact of this is to hold providers responsible for patient outcomes -- they will have an incentive to achieve good outcomes as efficiently as possible. What impact will this have on health care delivery? Would you, as a doctor, welcome or dread this? Any aspect of patients’ lives and worlds that interfere with health outcomes will become problems for health care providers. What would be needed for this system to work well? What are some possible unintended consequences?

Knowledge ProductionISM 2013: October 17th, 1:30-3:30

Overview:How (and why) do doctors know what we know, and where does that knowledge come from? How much can we trust the knowledge that is produced? Answers to these questions have changed dramatically over the past century. From case reports to case series and now to randomized clinical trials and evidence-based medicine, knowledge production has become a central force shaping medical practice. Doctors now have unprecedented access to extensive, high quality knowledge to guide diagnoses and treatment decisions. However, other, more biased, sources of information are also common, creating challenges for the clinician. While randomized clinical trials (RCTs) are the ‘gold standard’ for measuring efficacy, many physicians and policymakers are raising new questions about their generalizability and hence their relevance to clinical practice. Comparative effectiveness research is emerging as a major new source of information to guide clinical (and coverage) decisions, but it has been subjected to criticism by both politicians and industry. This week we will consider these problems and possible solutions. Using prescription drugs as an example, the lecture will explore how knowledge is produced, how these processes are shaped by FDA guidelines and industry interests, and what clinicians can do to ensure the availability and use of accurate and clinically relevant information. In tutorial we will examine a series of cases that involve potential conflicts of interest in medical research. The question is not whether or not a conflict exists, or whether the conflict is inappropriate. Instead, the challenge for students and doctors is to learn how to operate in a world where much of medical knowledge reflects a range of vested interests.

Key Concepts:production, circulation, and consumption of medical knowledgeconflicts of interest

Cases:In each of the following cases, decide whether the new knowledge would alter your clinical practice.

1. A large randomized trial demonstrates that a new diagnostic test can identify a new subset of patients with normal blood pressure in whom treatment with a particular class of antihypertensive medication is likely to reduce the incidence of cardiovascular events. The principal investigator of the study holds a patent on the diagnostic test and will earn millions of dollars each year if the trial’s results are incorporated into clinical practice.

2. The chief of psychiatry at your hospital advocates the use of a new antidepressant that is the S-isomer of an existing drug, arguing that it has slightly greater efficacy than the generic version of the drug (which is a racemic mixture of both the D and L isomers). The speaker is on the scientific advisory board of the maker of the new drug. At Grand Rounds he presents both published and unpublished data provided by the company indicating a marginal improvement on some scales of depression with use of the new drug, and notes his “clinical impression” that the newer drug is an important improvement.3. A prominent researcher has dedicated his professional career to developing a new class of medications for asthma. After years of work he develops a novel compound and conducts clinical trials that demonstrate the efficacy of this drug. He has no direct financial stakes in the success of the medication.

4. Epidemiological studies have shown that high HDL is associated with lower mortality from coronary artery disease. Researchers develop a drug that can raise HDL. In a randomized clinical study with 12-week follow-up, HDL increased in the patients treated with the active compound, but not in those treated with placebo. The researchers apply to the FDA to market the drug as a treatment for CAD.

5. After conducting an extensive meta-analysis of published research, the United States Preventive Services Task force recommends that screening mammography not be used routinely for women in their 40’s. Breast surgeons, radiologists, and patient advocates rebut this recommendation, citing their own evidence that screening mammography saves lives.

6. In 2010 Harvard Medical School changed its conflict of interest policy. All lecturers were required to disclose their conflicts at the start of a lecture. After hearing lectures from many prominent researchers, most of whom disclosed many ties to industry, some students laughed when a lecturer disclosed no conflicts: they figured that his research must not be very promising or interesting.

7. The alveolar cells in the lungs of premature infants do not produce sufficient surfactant; this can cause respiratory distress syndrome and death. Administration of surfactant can prevent these deaths. However, the high costs of neonatal care had prevented widespread use of surfactants in developing countries. When a company developed a new surfactant (the fifth), the FDA supported the company’s decision to conduct a double-blinded, randomized, placebo-controlled trial of the drug in Bolivia. Surfactant and intensive respiratory care had not previously been available at the participating hospitals.

Readings:

Avorn, Jerry. “Leaving the Dark Ages Behind, Mostly.” In Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs. New York: Random House, 2004. pp. 39-68. This chapter contrasts narratives of progress in the production and circulation of medical evidence with examples of persisting pockets of “irrationality” in how medical knowledge in disseminated through communities of physicians.

Timmermans, Stefan, and Aaron Mauck. “The Promises and Pitfalls of Evidence-Based Medicine.” Health Affairs 24 (January-February 2005): 18-28. No one is against “evidence-based medicine.” So why has it been so unsatisfying in practice? Is the problem how knowledge is produced or how it is utilized by doctors? How can the situation be improved?

Avorn, Jerry. “Approval of a Tuberculosis Drug Based on a Paradoxical Surrogate Measure.” JAMA 309 (3 April 2013): 1349-1350. There is an urgent need for new treatments for multi-drug resistant TB in the developing world. But can bureaucratic and industrial agendas produce knowledge that leads to counterproductive results?

Kesselheim, Aaron S., Michelle M. Mello, and Jerry Avorn. “FDA Regulation of Off-label Drug Promotion Under Attack.” JAMA 309 (6 February 2013): 445-446. The FDA has traditionally regulated the kinds of claims that manufacturers can make about the efficacy of their drugs. This regulation has now been challenged, on the grounds that it regulates the “free speech” of manufacturers. How should these competing interests be resolved, and by whom?

Avorn, Jerry. “Teaching Clinicians about Drugs -- 50 Years Later, Whose Job Is it?” New England Journal of Medicine 364 (31 March 2011): 1185-1187. The question is not just what knowledge is produced, but also how that knowledge gets disseminated to physicians. How have ideas about this shifted over time? What is the most appropriate mechanism today?

Learning Objectives:1. Understand how knowledge production in medicine reflects the

intersection of multiple interests: researchers, clinicians, marketers, shareholders, patient advocates, and government.

2. Understand why the data that clinicians want for rational decision making often are not available.

3. Recognize that the FDA and NIH lack the authority and resources needed to require comparative assessment of drugs and other therapies, and to adequately monitor the safety and efficacy of drugs in typical use, leaving doctors without knowledge they need to provide the best care.

4. Strategize about how doctors can best operate in an imperfect knowledge environment and what they can do to improve the situation.

Questionnaire:

Please complete the questionnaire about the case vignettes before noon on Wednesday.

Writing Assignment:Many of the readings this week speak to the surprising differences between the ways in which medical knowledge is formed and the way it is utilized (or not utilized) in policy and practice. For your writing assignment, pick a health problem that interests you (it does not have to be something we have discussed in this course) and examine the way in which an important fact has circulated. This can be done in either direction: you can start with one of the many facts being bandied about in general policy discussions and then try to understand the actual evidence bearing on that question and the specific conditions in which that claim was created, or you could start instead with a piece of original research and then track it forward to see how the details of the fact change as it is used by people (physicians, policymakers, politicians) who were not involved in the original research that produced such knowledge. How does evidence move from experimental observation to medical fact? What interests influence the circulation of the idea? With a bit of research on newspapers, blogs, or PubMed it should be easy to find an interesting claim that circulates widely that allows you to examine what is lost -- or gained -- in translation of medical facts from the sphere of research into the spheres of practice, policy, publicity, and markets. Please write up your 500-word discussion, informed by the class readings, and submit it to your tutor by noon on Wednesday.

Remember: you will be able to do a final paper on a topic of your own choice in place of the last four weekly writing assignments. It’s never too soon to start thinking about possible topics.

Questionnaire (10/17): Knowledge Production

Case 1: You study the new clinical trial and find that its methods and results seem rigorous. Would you:(a) begin to use the new diagnostic test in your patients(b) wait for additional studies by researchers without financial interests in the test

Case 2: After hearing the presentation by the chief of psychiatry, would you:(a) begin to use the new drug as first-line therapy for depression(b) wait for additional research by other researchers(c) continue to use generic medication because it is cheaper and works well enough

Case 3: On the basis of the studies produced by the researcher, would you:(a) begin to prescribe the medication in your patients(b) wait for additional studies by researchers who have not staked their professional reputation on the drug’s success

Case 4: Presented with data about the impact of the drug on HDL, the FDA should:(a) approve the drug for treatment of coronary artery disease(b) delay approval pending submission of data on clinical outcomes

Case 5: Faced with competing recommendations from expert panels, would you:(a) recommend continued screening of women in their 40’s(b) encourage women to delay screening mammograms until age 50.

Case 6: When listening to material presented by faculty, are you:(a) impressed by faculty with many industry relationships, as evidence that their research is important and relevant(b) impressed by faculty without any disclosures, because their material might be less biased

Case 7: As the director of one of the hospitals in Bolivia, would you:(a) agree to participate only if the company promised to fund ongoing respiratory care for your hospital’s patients after the trial had ended(b) agree to participate without this requirement(c) refuse to participate

Advocacy and Medicine Beyond the Clinic: Part 1ISM 2013: October 24th, 1:30-3:30

Overview:As we discussed in the first week of the course with the case of Santiago, there is more to providing good (e.g., high value) care than simply making a correct diagnosis and prescribing an evidence-based treatment plan. Is the patient able to follow the treatment plan through to success? This often does not happen and potentially efficacious treatments are often not as effective as they should be. Treatments sometimes fail because patients do not implement the plan scrupulously, a problem known as “non-compliance” (or “non-adherence”). But does responsibility always (or often?) reside in the patient? Treatment failure often happens because of the imperfect structure of our health care system and the complex social worlds in which patients live. As a result, doctors often have to reach beyond their clinics and hospitals and engage more substantially with patients’ social contexts and the structure of the health care system to achieve good health outcomes. This week we will begin with a tutorial that will introduce a series of patients (adapted from real patients, care fro by course tutors) to illustrate why it can be so hard to achieve good outcomes. Your goal there is to brainstorm about possible solutions. In lecture Heidi Behforouz, an internist at BWH, will describe a program that she started to improve outcomes in patients who have failed conventional therapy for HIV; the case of Mary is based on one of her patients. Her program, which was modeled on HIV treatment programs that were developed in Haiti, has itself served as a model for programs now being deployed in New York City and the Navajo Nation.

Key Concepts:non-compliance and non-adherenceimmodest claims of causalityresponsibility, for treatment outcomesadvocacyaccompanimentteamwork, professionalism, and inter-professionalismhealth literacy (and its limits)agency, constraint, and empowerment

Cases:1. Recall from Week 1: Santiago is an 8-year old boy who comes to your pediatric clinic for follow up after an ED visit the night before. His mother, Carmen, had taken him to the hospital last night because of respiratory distress -- his 8th serious asthma flare this year, two of which required hospitalization. Frequent ED visits are usually preventable with adequate asthma management.

2. Mary is a 37-year old woman with AIDS. One year after diagnosis she remains sick, with detectable viral loads and recurrent admissions for opportunistic infections. She has access to medications and a PCP who calls her whenever she misses appointments.

3. Richard is a 64-year old man with obesity, hypertension, diabetes, and coronary artery disease. His cardiologist, frustrated by his inability to eat less, exercise more, and take medications consistently, referred him to a new PCP (you) for on-going management of these problems.

4. John is a 24-year old man with mild to moderate depression. You started him on fluoxetine 6 months ago and have increased his dose steadily. He remains symptomatic. He comes to clinic today saying that he just saw an advertisement for Lexapro and would like to try that instead. In his chart, however, you see a note from his pharmacy benefits manager advising you that he has not refilled his prescription in the last four months.

5. Kelly, a 44-year old homeless alcoholic, develops active tuberculosis. She promises to take the 6-month course of antibiotics reliably, and quit alcohol (because of the hepatic toxicity of isoniazid). You are worried that she will not follow through.

6. Miguel is a 10-year old boy referred from school because of concerns about his behavior. He meets criteria for ADHD (teachers report: hyperactive, impulsive, inattentive, disruptive). His parents refuse the recommendation for stimulants; they say the teacher is the problem, not their son, and that he had no behavior problems in school last year in the Dominican Republic.

7. Robert is a 25-year old man who presents to an outpatient clinic in Haiti with active tuberculosis. He claims that he has been as compliant as possible with multiple prior courses of antibiotics, but that sometimes the drugs have not been available in Port-au-Prince.

8. Maria is a 37-year old woman with AIDS in South Africa. One year after diagnosis she remains sick, with detectable viral loads. She refuses to take her medicines because she does not have enough food: ARVs increase appetite and can cause intolerable hunger, and their side effects are worse if taken on an empty stomach.

9. Mark is a 2-year old in Rwanda with a patent ductus arteriosus. An NGO had arranged for him to have cardiac surgery in Sudan. The family refused to let him go, fearing that he might die away from home. He presents now with shortness of breath and congestive heart failure.

Readings:Farmer, “Social Scientists and the New Tuberculosis.” Social Science and

Medicine 44 (1997): 346-358. Tuberculosis has long been a focal point for anxieties about non-compliance. Farmer (especially pp. 351-356) critiques common explanations of non-compliance. What are “immodest claims of causality,” and why is it important to recognize them?

Behforouz, Heidi L., Paul E. Farmer, and Joia S. Mukherjee. “From Directly Observed Therapy to Accompagnateurs: Enhancing AIDS Treatment Outcomes in Haiti and in Boston.” Clinical Infectious Diseases 38 suppl 5 (2004): S429-S436. When is DOT not enough? What additional value is provided by accompagnateurs? What is needed to make this kind of social medicine scalable and sustainable?

Gawande, Atul. “The Hot Spotters: Can We Lower Medical Costs By Giving the Neediest Patients Better Care.” New Yorker (24 January 2011): 41-51. What is hotspotting? Who are the superutilizers? Gawande uses a series of case studies to show how social science can help to design innovative forms of intensive outpatient care. What is needed to make this kind of social medicine sustainable?

Learning Objectives:1. Recognize what “non-compliance” might reveal about the treatment, the

patient, the providers, and the patient-doctor relationship.2. Understand why achieving excellent health outcomes often requires more

than just prescribing medications during office visits.3. Recognize the strengths and weaknesses of different models of aggressive

outpatient care as well as the kinds of reforms that would have to be implemented in health care and reimbursement systems to make them viable.

Questionnaire:Please complete the questionnaire about the case vignettes before noon on Wednesday.

Writing Assignment:You have three choices for the writing assignment. Please write-up a 500 word discussion and send it to your tutor before noon on Wednesday. Please make good use of the readings.

(1) Based on the cases and readings, describe what level of responsibility you think doctors should take for achieving the best health outcomes for their patients. Regardless of whether you put most of the responsibility on

patients or on doctors, be sure to defend your position and address likely counter-arguments. What would be the consequences (for patients, for providers) of the position you defend?

(2) Physicians at Children’s Hospital (led by our own Eric Fleegler) have developed an online resource, HelpSteps, that helps physicians help patients who struggle with difficult social circumstances. This website allows patients to enter basic information about their lives (e.g., their social history) and then receive information about social services that are available to help them. For this assignment, use HelpSteps to find out what kinds of services might be available for one of the cases. Imagine that you are the individual patient when answering the questions. Go to the HelpSteps website (www.helpsteps.com) and follow the prompts from there (e.g., Get Started, then Guided Search). Feel free to make up details that seem plausible for your case. For instance, when it asks for the address, pick one of the neighborhoods that you explored on the walking tour. Write up a description of what you found and your assessment of how helpful that information would be.

(3) Consider the patients you have met so far in Patient-Doctor 1. Have they had optimal health care experiences and outcomes (e.g., have they experienced the full benefit that could be expected given their diagnosis and the therapeutic state of the art)? If yes, what combination of factors made it possible? If not, what went wrong and what might help remedy the situation? You can focus on one patient or discuss several. Be sure to think broadly about the patients and their social contexts, their providers, and their health care institutions

Questionnaire (10/24): Caring for Complex Patients

Case 1: Based on our discussion of Santiago in the first week of the course, which cause of treatment failure would you focus on? Ideally, of course, you would be able to address everything.(a) Establishing consistent primary care with his pediatrician.(b) Improving Carmen and Santiago’s understanding of asthma and asthma management.(c) The conditions in Santiago’s home environment.

Case 2: How aggressively would you pursue Mary to ensure compliance with ARV’s?(a) Recognize that she can choose to comply or not, and leave treatment in her hands.(b) Call her whenever she misses appointments.(c) Arrange for a home visit to better understand what is happening.(d) Implement a program of directly observed therapy (note: most insurers will not pay for visits that take place at home) (note: what would you do if she refuses?).

Case 3: How aggressively would you pursue Richard to ensure optimal management of his obesity, diabetes, and coronary artery disease?(a) Recognize that he can choose to comply or not, and leave treatment in his hands.(b) Call him whenever he misses appointments.(c) Arrange for a home visit to better understand what is happening.(d) Implement a system of home monitoring that includes: electronic pill bottles that transmit when they are opened and closed; a bathroom scale that transmits his weight each day to your clinic; home blood pressure monitoring.

Case 4: When you broach the question of non-compliance, John insists that he has taken fluoxetine reliably. Would you:(a) Write a prescription for Lexapro, knowing that it is more expensive and likely to be no more effective (assuming that either is taken reliably).(b) Tell him what you have learned from the pharmacy benefits manager as a way of motivating a franker discussion of non-compliance.(c) Offer to check a serum fluoxetine level, saying that you want to see whether he is a rapid metabolizer of the drug (e.g., get a lab test as way of more politely outing his non-compliance).

Case 5: You are quite confident that Kelly will not follow through with this treatment plan. Would it be appropriate to hospitalize her -- even against her will (e.g., at the Shattuck Hospital) -- until she has completed therapy?(a) Yes(b) No

Case 6: How would you respond to Miguel’s parents:(a) Ally with Miguel’s teachers and work to get Miguel on stimulants.(b) Try to obtain school records from the Dominican Republic.(c) Ally with Miguel’s parents and pressure the school to make changes in the classroom.(d) Work to understand the parent’s concerns about stimulants.

Case 7: What would you do first in order to help Robert:(a) Admit him to the hospital for isolation and directly observed therapy.(b) Arrange for a community health worker to provide directly observed therapy to Robert as an outpatient.(c) Ask him to obtain records from past treatment so that you can develop an informed plan.(d) Something else.

For Case 8 and Case 9 think about possible solutions that would allow the medical care to proceed.

EfficacyISM 2013: October 31th, 1:30-3:30

Overview:In our discussion of value, Michael Porter defined value as outcomes relative to cost. As they described, it is can be difficult to know which outcomes matter most. Jerry Avorn described some of the obstacles to evidence based medicine. RCTs, for instance, often conducted to win FDA approval, do not always produce the knowledge that doctors want. The problem of understanding treatment outcomes -- the efficacy of medical interventions -- is a fundamental challenge for medicine. The complexities emerge at two levels: the impact of a particular intervention on a patient, and the impact of medical systems on the health of populations. The history of medicine is full of surprising case studies about therapeutic efficacy, and by studying these cases it is possible to gain insight into the nature of efficacy. Why did some therapies that are now believed to be useless remain popular for decades, even centuries? Why do some therapies with excellent physiological rationales not improve clinical outcomes? Why is it so hard to demonstrate that our health care system actually improves our health? Lecture will review the social science of efficacy and therapeutic systems, examining interesting case studies of therapeutic efficacy (e.g., bloodletting, lobotomy, psychotherapy). It describes prominent critiques leveled against our health care system and possible responses. Tutorial will look more closely at the many meanings of therapeutic efficacy, based on your interviews of people who have gone through medical treatments.

Key Concepts:therapeutic systemefficacy and effectivenessmagic bullets (and the limits of reductionism)role of medicinenon-compliance and non-adherence

Case:Find a person who has had a significant illness episode and medical intervention (parent, grandparent, friend -- do not coopt a Patient-Doctor 1 interview for this purpose) and ask them whether or not the treatment worked. Pay close attention to how they answer this question. If the treatment did not work, find out what hopes they had for treatment, what expectations their doctor set, what outcomes they experienced, and why they interpreted the treatment as a failure. If the treatment did work, ask how the efficacy was experienced: does your informant describe relief of symptoms, ideas about how the therapeutic mechanism addressed the underlying cause of the problem, evidence produced by imaging or

laboratory tests, or an anticipated improvement in probability of survival? Most people will discuss efficacy at several of these levels. Pay very close attention to their language. If your informant is unreflective, ask more specific questions: What did the treatment feel like? What impact did it have on their experience of disease? Did the person have faith in their doctor? etc. Be sure to ask your informant about whether or not patient and doctor agreed about their assessment of therapeutic efficacy.

Readings:Jeremy A. Greene, D.S. Jones, and Scott H. Podolsky. “Therapeutic Evolution

and the Challenge of Rational Medicine.” New England Journal of Medicine 367 (September 2012): 1077-1082. This short essay describes how therapeutics and thinking about therapeutic efficacy have changed over the past two centuries.

Kaptchuk, Ted J. “Placebo Studies and Ritual Theory: A Comparative Analysis of Navajo, Acupuncture, and Biomedical Healing.” Philosophical Transactions of the Royal Society B 366 (2011): 1849-1858. Kaptchuk, who runs a center for placebo studies at BIDMC, offers an insightful analysis of the different ways in which treatments might work.

Brandt, Allan M. “The Syphilis Epidemic and Its Relation to AIDS.” Science 239 (22 January 1988): 375-380. Writing in the early years of the AIDS epidemic, Brandt discusses the appeals and limits of biomedical interventions (“no magic bullet”). Does this need to be rethought twenty-five years later? ARVs have had a dramatic impact on AIDS -- but why did it take fifteen years for their impact to be visible on a global scale?

Learning Objectives:1. Recognize the many different ways that patients and doctors have of

thinking about whether or not a treatment works, and how misunderstandings about treatment efficacy can emerge in patient-doctor relationships.

2. Understand the critiques that have been made about medicine, both of individual treatments and of the health care system overall. Recognize the merits and limitations of these critiques.

3. Begin to develop a nuanced and realistic expectation of what can be achieved with medical interventions.

Questionnaire:None this week.

Writing Assignment:

Before noon on Wednesday, please write a 500 word discussion of your informant’s experience of therapeutic efficacy. Did the treatment work? What was the basis of this assessment? Did the patient and doctor agree? Be sure to use the readings to inform your analysis.

Remember: you will be able to do a final paper on a topic of your own choice in place of the last four weekly writing assignments. It’s never too soon to start thinking about possible topics. What would this involve? Instead of the weekly assignments for the last four weeks of the course (11/14, 11/21, 12/5, 12/12), you can work on a single, more sustained writing project of your own choice, which will be due on 12/12.

Is there a topic related to social medicine, whether in the US or overseas, that you would like to study in more detail? Have your other courses raised interesting questions for social medicine? Do you have ideas about possible summer research projects? Do you want to explore the social medicine contexts of your PIM proposal? All are fair game.

These projects can take the form of informed and thoughtful commentaries on a topic, a brief literature review, or an initial proposal for further research. You will likely need to do outside reading to obtain the background needed to write something thoughtful, interesting, scholarly, and useful. Final details can be negotiated between you and your tutor. Feel free to contact any of the tutors, or other DGHSM faculty listed in the syllabus, for advice and guidance.

You may also collaborate with other students on the larger project. If you are interested in doing so, you must discuss your proposal with each of the relevant tutors in advance. Everyone involved needs to have a clear understanding about expectations for the nature of the work and the specific contribution of each student.

If you choose this option, you must send your tutor a paragraph before tutorial on 11/14 describing your interests and plans.

*** Whatever option you choose, you must, of course, still be prepared to discuss the required readings each week in tutorial and lecture. ***

Advocacy and Medicine Beyond the Clinic, Part 1I Medical-Legal Partnership: Moving from Patients to Policy

ISM 2013: November 7th, 1:30-3:30

Overview:Class two weeks ago began in tutorial with a discussion of patients who have not had optimal health outcomes. We began to brainstorm about how we might address their problems. Then in lecture we learned about the PACT Program, an example of one possible solution. This week we will move the discussion from individual patients to clinical systems and policies that impact health, and in particular, structural barriers with legal underpinnings that may also impact a person’s health and treatment success. The Medical Legal Partnership is a model for incorporating lawyers on the health care team to identify and redress health problems that arise completely or in part when laws are not followed (e.g. a patient with asthma has substandard because the landlord is not maintaining the apartment up to code) and inform policymakers and advocate for policy changes that positively impact health. As you continue your education and training to become doctors, you will define your role as a physician and determine for yourself how you can integrate this into your practice. Lawyers have a key role to play on multidisciplinary teams and inter-professional work in health care. In tutorial we will revisit the patients from two weeks ago, this time with an eye towards thinking about how to advocate for them both within and outside of the clinical setting. Does an existing policy need to be changed, or a new policy developed? What are examples of how physicians, when working with other advocates, can be powerful forces for change?

Key Concepts:teamwork, professionalism, and inter-professionalismlegal roots of the social determinants of healthdisparitiesadvocacy

Cases: 1. Recall from Week 1: Santiago is an 8-year old boy who comes to your pediatric clinic for follow up after an ED visit the night before. His mother, Carmen, had taken him to the hospital last night because of respiratory distress -- his 8th serious asthma flare this year, two of which required hospitalization. Frequent ED visits are usually preventable with adequate asthma management.

2. Mary is a 37-year old woman with AIDS. One year after diagnosis she remains sick, with detectable viral loads and recurrent admissions for opportunistic infections. She has access to medications and a PCP who calls

her whenever she misses appointments.

3. Richard is a 64-year old man with obesity, hypertension, diabetes, and coronary artery disease. His cardiologist, frustrated by his inability to eat less, exercise more, and take medications consistently, referred him to a new PCP (you) for on-going management of these problems.4. John is a 24-year old man with mild to moderate depression. You started him on fluoxetine 6 months ago and have increased his dose steadily. He remains symptomatic. He comes to clinic today saying that he just saw an advertisement for Lexapro and would like to try that instead. In his chart, however, you see a note from his pharmacy benefits manager advising you that he has not refilled his prescription in the last four months.

5. Kelly, a 44-year old homeless alcoholic, develops active tuberculosis. She promises to take the 6-month course of antibiotics reliably, and quit alcohol (because of the hepatic toxicity of isoniazid). You are worried that she will not follow through.

6. Miguel is a 10-year old boy referred from school because of concerns about his behavior. He meets criteria for ADHD (teachers report: hyperactive, impulsive, inattentive, disruptive). His parents refuse the recommendation for stimulants; they say the teacher is the problem, not their son, and that he had no behavior problems in school last year in the Dominican Republic.

7. Robert is a 25-year old man who presents to an outpatient clinic in Haiti with activetuberculosis. He claims that he has been as compliant as possible with multiple prior courses of antibiotics, but that sometimes the drugs have not been available in Port-au-Prince.

8. Maria is a 37-year old woman with AIDS in South Africa. One year after diagnosis sheremains sick, with detectable viral loads. She refuses to take her medicines because she does not have enough food: ARVs increase appetite and can cause intolerable hunger, and their side effects are worse if taken on an empty stomach.

9. Mark is a 2-year old in Rwanda with a patent ductus arteriosus. An NGO had arranged for him to have cardiac surgery in Sudan. The family refused to let him go, fearing that he might die away from home. He presents now with shortness of breath and congestive heart failure.

Readings: Sandel M, Hansen M, Kahn R, Lawton E, Paul E, Parker V, Morton S,

Zuckerman B. “Medical-Legal Partnerships: Transforming Primary Care

By Addressing The Legal Needs Of Vulnerable Populations.” Health Affairs 29 (2010): 1695-1705. This article provides the rationale for the medical-legal partnership, its history, expansion and examples of how it operates. Why do the authors think MLP should be integrated into federal health programs?

Schroeder, Steven A. “We Can Do Better – Improving the Health of the American People.” New England Journal of Medicine 357 (20 September 2007): 1221-1228. Schroeder, an HMS alum and former president of the RWJF, argues that physicians need to work more broadly as advocates for their patients. How does he move from the burden of disease, to social determinants, to his vision for health care today?

Williams DR, Costa MV, Odunlami AO, Mohammed SA. “Moving Upstream: How Interventions That Address the Social Determinants of Health Can Improve Health and Reduce Disparities.” Journal of Public Health Management and Practice. 14 Suppl (2008):S8-S17. Williams, a professor at HSPH, states that in order to reduce disparities, we need to address social determinants of health both within and outside the health system. Why does he argue for targeted interventions for the most disadvantaged?

Teufel JA, Werner D, Goffinet D, Thorne W. “Rural Medical-Legal Partnership and Advocacy: A Three-Year Follow-up Study.” Journal of Health Care for the Poor and Underserved 23 (2012): 705-714. The authors demonstrate the cost-effectiveness of a rural MLP. In light of what we learned about the PACT program, how do these authors calculate cost-benefit and return on investment? What is the relative importance of these economic results in comparison to improved social results?

Learning Objectives:1. Understand that many social determinants of health have legal roots and

require legal care (e.g., the Medical-Legal Partnership as one model).2. Learn how patients, doctors, and legal systems can collaborate to increase

the likelihood of achieving good treatment outcomes.3. Discuss the unique role that physicians can play as advocates for policy

change.

Writing Assignment:Submit your essay (500 words maximum) on one of the following two topics to your tutor by noon on Wednesday.

1. Think back to Dr. Kasper’s lecture on poverty and her advocacy efforts to get food stamps restored to legally present immigrants. Consider the patients you have met so far in Patient-Doctor 1. Do they have a health issue that is impacted by current health and/or other policies or legal issues?

Or do they have a health issue that would benefit from advocacy work at a systemic level? If so, describe the health problem, the relevant policy or legal underpinnings, and devise an advocacy strategy to address the problem.

2. Think of a health issue you are passionate about (e.g. rights of the disabled, disparities in health care, how to fix our health system, etc.). Then read the Advocacy 101 primer (see below) that describes how to write an elevator speech, Op-Ed or blog. Indicate whether your paper is an elevator speech, Op-Ed or blog; don’t forget to tell us who your audience is (e.g. the mayor, the head of Health and Human Services, President Obama, the US general public). Two examples of blogs written by Dr. Sandel will give you an idea of how to structure your piece:

“Creating the Social Determinants of Health Vital Sign” (July 26, 2013): http://medical-legalpartnership.blogspot.com/2013/07/creating-social-determinants-of-health.html#!/2013/07/creating-social-determinants-of-health.html

“The New Personalized Medicine” (August 9, 2013): http://medical-legalpartnership.blogspot.com/2013/08/the-new-personalized-medicine_9.html

There is also an example at the end of the Advocacy 101 primer regarding the Bush administration and Social Security.

*** Thinking Ahead ***

After this week there are four more weekly writing assignments (11/14, 11/25, 12/5, 12/12). Instead of the weekly assignments for these last four weeks, you can work on a single, more sustained writing project of your own choice, due on 12/12.

This larger project could take many forms. You can use the final weeks to pursue a specific interest, related to social medicine, whether in the US or overseas. Is there a topic from this course that you would like to study in more detail? Have your other courses raised interesting questions for social medicine? Do you have ideas about possible summer research projects? Do you want to explore the social medicine contexts of your PIM proposal? Would you like to explore more deeply the home visit you made as part of PD1? All of these are fair game.

These projects can take the form of informed and thoughtful commentaries on a topic, a brief literature review, or an initial proposal for further research.

You will likely need to do outside reading to obtain the background needed to write something thoughtful, interesting, scholarly, and useful. Final details can be negotiated between you and your tutor. Feel free to contact any of the tutors, or other DGHSM faculty listed in the syllabus, for advice and guidance.

You may also collaborate with other students on the larger project. If you are interested in doing so, you must discuss your proposal with each of the relevant tutors in advance. Everyone involved needs to have a clear understanding about expectations for the nature of the work and the specific contribution of each student.

If you choose this option, you will submit a brief description of your plans to your tutor as the 11/14 writing assignment.

Advocacy 101

Doctors can make great advocates!• Respected position in society• Seen as smart• Seen as having best interests of people at heart• Connecting issues to health (especially child health) can be very

powerful• When we talk, people listen

Ways doctors can advocate• With agencies/organizations/schools, for specific patient/family• Legislative advocacy (spoken, written)• Media

– Written (blogs, OpEds, letters to the editor)– Interviews (radio, TV, quotes for articles)

Message is key! Message development principles: CLEAR – message needs to be brief, with max of 3-4 key points CONNECT – message needs to have some relevance to the reader;

appeal to what the audience cares about; means you need to know your audience

COMPELLING – message needs to be interesting; use analogies, metaphors, a personal experience, or a startling statistic to get people’s attention

THE “DOs”• Help people understand the issue in plain, simple language – tell a

story; place the problem in context; couch it in a shared value• Make people care – you can speak from personal experience (e.g. “the

patients I care for…”)• Make people act

– Elicit desired behaviors – you give them a solution and a sense of urgency

– Spread the word– Call to action should be simple, practical and achievable– Give them a vision of the outcome/benefit

THE “DON'Ts” Don’t use jargon Don’t be verbose Don’t bury your message Don’t forget the ACTION STEP

The Elevator Speech Key Components• Short: 30-60 seconds

• Aimed at your audience• Gets right to the point• One or two points best (three max)• Catchy, simple language• Real (patient story) and/or relevant (how does it affect the audience

directly?)• Clear call to action

The Op-Ed or Blog Key Components• Make it timely, link it to current news• An opening sentence that grabs people’s attention• Make your point early – best to focus on one message• Reading level no higher than 7th grade• Conversational, active voice• Break it up visually (for blogs: images!)• Make your case—structure the content• Stats/factoids help (but don’t overuse)• Ending that ties it up – end with a bang• Keep it short (400-750 words)

Letters to Editor Key ComponentsSame principles as blogs/op-eds, except…• Respond to an article (or lack of one)• Brief! Check w/newspaper for word count limit• Make one point• Be clear and straightforward—important with short word count.

How to frame your story: e.g., Bush administration on Social Security, 2005PROBLEM: Social Security will go bankrupt

Bigger shortfalls every year 2018 we will be paying more than taking in 2042 we will be bankrupt Costs more to do nothing

VISION: Greater retirement security Greater returns over time Pass on these returns to your children

SOLUTION: Pass reforms now Work with Congress/anyone who has a good idea Permanent fix Guarantees for older workers Better deal for younger workers Cheaper to start now

ACTION: Voluntary personal retirement accounts Choice, options Ownership Your money

Greater returns

Tutorial Tutorial could focus on the following: “What do you all make of what Heidi and Megan have put on the table — the call for physicians to work as advocates as well as physicians?” Or you can use the time to have students share their reflection papers/elevator speeches/op-eds, discuss the readings or the lecture, and continue the conversation about complex patients that they began to delve into the week of 10/24 (when Heidi spoke about PACT). The vignettes are above. Included in the students’ guide are some basic notes about advocacy that the students will use when writing their reflection paper.

Global Health StrategyISM 2013: November 14th, 1:30-3:30

Overview:With many of the challenges facing patients and doctors now, in both the United States and abroad, it is not too difficult to imagine potential solutions to a problem. It is, however, often difficult (impossible?) to mobilize the necessary political will and human, material, and financial resources to achieve solutions to these problems. Doctors committed to improving health care often need to think strategically and collaboratively to solve the problems they face; for instance conducting targeted research to generate new knowledge (or debunk myths) that will justify intervention and motivate the needed support. The lecture will describe one successful example of this approach: an effort in the late 1990s led by a group of HMS faculty and students to change WHO policy about treating multi-drug resistant tuberculosis. MDR-TB had been increasingly recognized worldwide, but WHO had decided that it would not commit resources to treating patients with MDR-TB in resource-poor settings; treatment was too long, too expensive, and too difficult. Work by Carole Mitnick, Sonya Shin, and others led WHO to change this policy. Other efforts, occurring in parallel, led to an even more dramatic change in HIV policy: the decision by WHO, the World Bank, and PEPFAR to make ARVs available as widely as possible. Both programs -- MDR-TB and HIV -- face many obstacles. They are emblematic of the many challenges facing health programs in resource-poor settings. In the global health panel discussion, you will hear from faculty engaged in different, cutting edge strategies for tackling some of the most pressing issues in global health: Bepi Raviola, Paul Farmer, Jen Kasper, Kris Olsen, Sadath Sayeed, and Rebecca Weintraub. And in the spirit of examining the synergies between global and domestic health, they will discuss reverse innovation and identify ways these same strategies can be employed in the US to tackle our most pressing problems.

Key Concepts:international health and global healthglobalization and global social changeimplementation and accessreverse innovation

Cases:1. In 2002 AIDS experts at UCSF conducted a cost-effectiveness analysis and concluded that HIV prevention in sub-Saharan Africa was 28-times more cost effective than treatment with antiretroviral therapy. They argued that funding should be focused on prevention programs, not on treatment. How

would you make a case against this position? (Marseille et al., Lancet 2002; 359:1851-6).

2. In response to concerted advocacy, WHO changed its policy in 2006 and began to recommend treatment of patients with MDR-TB. Despite this, less than 1% of patients with MDR-TB worldwide receive adequate treatment. What might have gone wrong? (Keshavjee and Farmer, NEJM 2012; 363:1781-3).

3. Your organization gets a grant from PEPFAR to initiate ARVs in Mozambique. You look at existing models and see that some programs try to enroll as many patients as possible and leave a high burden of responsibility on the patient to follow through with the treatment, while other programs enroll fewer patients but through diligent work with community health workers ensure that all patients follow through with the treatment. Which approach will you pursue?

4. After the Port-au-Prince earthquake in 2010 (or in Aceh, after the Indian Ocean Tsunami in 2005), clinicians find a population struggling with acute-on-chronic mental health problems. Long standing poverty and political strife, compounded by the acute stress of the natural disaster, have resulted in many people suffering from PTSD, anxiety, and depression. Adequate mental health services did not exist prior to the disaster. Few resources exist for creating new services. How might you begin an effort to make mental health care available to the population?

5. When the Obama Administration came to power in 2009, it sought to expand the focus of its global health programs beyond PEPFAR to include other health priorities, especially maternal and child health. AIDS advocates saw this as a betrayal of the promise made by the Bush Administration. Obama officials countered that AIDS was just one of many health problems facing populations in resource poor settings. How can this tension be resolved? (Stolberg, “Obama Seeks a Global Health Plan Broader than Bush’s AIDS Effort,” NYT 5 May 2009).

6. An NGO sets out to define priorities for its ongoing efforts to improve health care in developing countries. It proposes five priorities: (1) HIV/AIDS, (2) maternal mortality, (3) pediatric care, specifically an effort to end child malnutrition, (4) access to surgery, and (5) improved access to care for acute and chronic diseases. One of the NGO’s physicians asks “what about TB?” What are the pros and cons of identifying priorities like these?

Readings:Kleinman, Arthur. “Four Social Theories for Global Health.” Lancet 375 (1

May 2010): 1518-1519. This essay distills the key contributions of

social theory to medicine down to two pages. What does Kleinman mean by “the unintended consequences of purposive action,” “the social construction of reality,” “social suffering,” and “biopower”? How is each relevant for social medicine, whether in local or global contexts? How can social theory be used not to attack medicine but to improve it?

Keshavjee, Salmaan, and Paul E. Farmer. “Tuberculosis, Drug Resistance, and the History of Modern Medicine.” New England Journal of Medicine 367 (6 September 2012): 931-936. Policy towards tuberculosis has changed dramatically over the course of the twentieth century. Why does the disease remain so prevalent despite the existence of effective therapy? What else needs to be done?

Ruxin, Josh. “Doctors Without Orders.” Democracy 9 (Summer 2008): 32-43. Why are funding, personnel, and supplies on their own not adequate to solve the problems of global health delivery? How can management science help? To what extent is good management a property of the manager or the architecture of institutions?

Kasper, Jennifer, and Francis Bajunirwe. “Brain Drain in sub-Saharan Africa: Contributing Factors, Potential Remedies, and the Role of Academic Medical Centers.” Archives of Diseases in Childhood 97 (2012): 973-979. One of the major challenges facing many countries is the lack of adequate human resources for health care. This piece describes how collaborative programs with academic medical centers might help.

Other Useful Resources:Global Health Delivery Online: www.ghdonline.org Global Health Service Corps: Seed Global Health: www.seedglobalhealth.org Center for Integrated Medicine and Innovative Technology (CIMIT): www.cimit.org Partners in Health: www.pih.orgDoctors for Global Health: www.dghonline.org Daktari Diagnostics: http://www.daktaridx.com/

Learning Objectives:1. Understand the complex origins of global health problems: global health

must be understood as a product of on-going epidemiological, commercial, political, and technological change.

2. Understand how specific strategies can be implemented to change both global health policy and health care delivery.

3. Recognize parallels between the challenges of health care delivery in Boston and in resource-poor settings worldwide. When can programs and strategies be moved between settings, and when must programs be designed for specific local contexts?

Questionnaire:Please complete the questionnaire by noon on Wednesday.

Writing Assignment: Please write a 500-word response to one of the two prompts below -- and be sure to make good use of the readings. If you plan to write a final paper in lieu of the writing assignments for the remainder of the course, see the instructions below. Regardless of which of these three options you choose, submit your response to your tutor by noon on Wednesday.

(1) Pick one of the cases above and describe what you would do. What strategy would you pursue? How would you make the case that your choice is the right one? How might you mobilize the social resources and political support that you would need in order to succeed?

(2) A recent episode of “This American Life” focused on poverty-alleviation strategies in resource-limited settings. Reporters from Planet Money compare the practices of Give Directly (give money directly to the poor people who need it, and let them decide how to spend it) and Heifer International (they give a cow to poor families, and that family gives away the first calf to another needy family). Do you think it is more effective to give money or give things and training? Choose a side and describe your arguments for and against your position. Go to the following website to listen to the podcast: http://www.thisamericanlife.org/radio-archives/episode/503/i-was-just-trying-to-help.

(3) Final Project Option: With this week and the three that follow, there are four more weeks in ISM (11/14, 11/21, 12/4, 12/12). Instead of the weekly assignments for these last four weeks, you can work on a single, more sustained writing project of your own choice, which will be due on 12/12.

This larger project could take many forms. You can use the final weeks to pursue a specific interest, related to social medicine, whether in the US or overseas. Is there a topic from this course that you would like to study in more detail? Have your other courses raised interesting questions for social medicine? Do you have ideas about possible summer research projects? Do you want to explore the social medicine contexts of your PIM proposal? All are fair game.

These projects can take the form of informed and thoughtful commentaries on a topic, a brief literature review, or an initial proposal for further research. You will likely need to do outside reading to obtain the background needed to write something thoughtful, interesting, scholarly, and useful. Final details

can be negotiated between you and your tutor. Feel free to contact any of the tutors, or other DGHSM faculty listed in the syllabus, for advice and guidance.

You may also collaborate with other students on the larger project. If you are interested in doing so, you must discuss your proposal with each of the relevant tutors in advance. Everyone involved needs to have a clear understanding about expectations for the nature of the work and the specific contribution of each student.

If you choose this option, you must send your tutor a paragraph before tutorial on 11/14 describing your interests and plans.

*** Whatever option you choose, you must, of course, still be prepared to discuss the required readings each week in tutorial and lecture. ***

Questionnaire (11/14): Global Health Strategy

Case 1: Faced with the argument that prevention is more cost-effective than treatment, would you:(a) Argue that cost-effectiveness analyses should not be a decisive factor in health policy decisions.(b) Challenge the methods or assumptions of this particular analysis (e.g., arguing that it misjudged either the cost or benefits of treatment).(c) Make a different case -- if so, please email your tutor to describe it.

Case 2: Of the following factors, which one do think is the most significant cause of the slow progress against MDR-TB?(a) Lack of funding.(b) Prioritization of other problems.(c) The difficulty of treating patients with MDR-TB.(d) Failure to make adequate treatment available to patients.

Case 3: Which approach would you take when you launch an ARV treatment program in Mozambique?(a) Make treatment available to as many patients as possible, and rely on them to follow through with treatment.(b) Enroll fewer patients, but ensure that each enrolled patient achieves an undetectable viral load.(c) Pursue a different strategy -- if so, please email your tutor to describe it.

Case 4: As you work to create a mental health system in Aceh (or Haiti), would you begin by:(a) Establishing a treatment center in a major population center, staffed by highly trained mental health professionals, who could provide high quality services to patients referred in for care.(b) Training community health workers to offer psychotherapy and basic psychopharmacology to patients in the community.

Case 5: When approached by the Obama Administration to offer advice, would you recommend that they:(a) Preserve funding for PEPFAR, because it has been a signature program, it has successfully recruited other resources to global health, and it has had spill-over effects that benefit other health initiatives.(b) Reallocate funding from PEPFAR to other priorities (e.g., maternal and child health), so that funding more adequately addresses the full burden of disease.

(c) Make the case to the American public that the US needs to increase its foreign aid so that funding could be increased for both PEPFAR and other health priorities.

Case 6: When asked by the NGO for an opinion about its health care priorities, would you recommend that they:(a) Articulate a set of priorities that reflect the local burden of disease.(b) Articulate a set of priorities based on their areas of expertise.(c) Avoid articulating priorities, since doing so might become divisive.(d) Do something different -- if so, email your tutor and describe your idea.

Disparities in Treatment Access and OutcomeISM 2013: November 21st, 1:30-3:30

Overview:In the opening weeks of the course we explored one set of problems related to health disparities: disparities in the burden of disease that arise, in part, from the social determinants of disease. Now we take up a distinct issue: disparities in treatment access and outcome. This issue is one of the great challenges facing anyone interested in providing value in health care. Disparities exist by geography (at local, national, and international scales), race and ethnicity, gender, insurance, socioeconomic status, and many other axes. Lecture will introduce the problem by presenting evidence on the different sorts of disparities that exist and on their possible causes. Tutorial will provide an opportunity to dig into a few cases in more detail in an effort to grapple with significant unresolved questions: when is a practice variation justified (i.e., what is warranted vs. unwarranted variation, or, in the language of the IOM, what is the distinction between different and disparity)? What are the most likely causes of inappropriate variations? What are possible solutions to these problems? All of this material is hugely politicized in the United States. Why does the disparities literature focus on race, when class might be a more relevant factor? Why does NIH require researchers to take race/ethnicity so seriously? So one of the questions is how can we, as students, doctors, or scholars, most productively navigate a politicized environment? We will return to this question on 12/5.

Key Concepts:difference and disparity: race, sex, gender

Cases:1. A study of pain management for patients with long-bone fractures in a Los Angeles Emergency Department found that Hispanic patients were twice as likely as non-Hispanic white patients to receive no pain medication. (Todd et al, JAMA 1993;269:1537-1539)

2. A study of renal dialysis found that in 1993 only 36% of black patients received an adequate dose of hemodialysis, compared with 46% of white patients. (Sehgal, JAMA 2003;289:996-1000)

3. In the United States in 2006 men were significantly more likely than women to receive coronary angioplasty with stenting (290 vs. 150/100,000) and coronary artery bypass surgery (219 vs. 81/100,000). (CDC, National Hospital Discharge Survey: 2006 Annual Summary, 2010)

4. In a 2009 study of 418 hospitals, black patients were 25% less likely to receive coronary revascularization than white patients with similar insurance. (Cram, J Natl Med Assoc 2009;101:1132-1139)

5. A 2009 study found that in patients with severe coronary artery disease, rates of coronary artery bypass surgery were lower in patients who were morbidly obese (BMI > 40) than in those who were not (55.3 vs. 61.5%). (Turer et al., J Thorac Cardiovasc Surg 2009;137:1468-1474)

6. In the United States in 2006, rates of both angioplasty with stenting and bypass surgery varied between geographic regions: Midwest (307 and 185/100,000), South (204 and 167/100,000), Northeast (198 and 116/100,000), and West (173 and 111/100,000), (CDC, National Hospital Discharge Survey: 2006 Annual Summary, 2010)

7. In the first 30 days after a heart attack, patients in the United States are far more likely than those in Canada to receive coronary angiography (34.9 vs. 6.7%), angioplasty (11.7 vs. 1.5%) and bypass surgery (10.6 vs. 1.4%). One-year mortality rates were identical (34.3 vs. 34.4%). (Tu et al, NEJM 1997;336:1500-1505)

8. Rates of coronary revascularization are nearly 300-times higher in Germany than in Mexico (582 vs. 2/100,000), despite similar rates of coronary artery disease mortality (men: 110 vs. 103/100,000, women: 56 vs. 65/100,000). (OECD, Health at a Glance, 2011)

9. In 2007 Medicare spending per capita in McAllen, Texas was $14,817. In El Paso, 800 miles up the border with similar public health statistics, spending was just $7947 per enrollee. (Franzini et al, Health Affairs 2010;29:2302-2309)

10. A 2011 study of patients with severe depression and access to electoconvulsive therapy found that ECT was far less likely to be used for black patients than for white patients (3.9 vs. 11.8%). (Case et al., J Affective Disorders 2011;doi:10.1016/j.jad.2011.11.026) More generally black patients are less likely to receive care for depression; care received is less intensive, of lower quality, and less likely to be provided by psychiatrists.

Readings:Wennberg, John. “Unwarranted Variations in Healthcare Delivery: Lessons

for Academic Medical Centers.” BMJ 325 (26 October 2002): 961-964. Wennberg, who established the Dartmouth Atlas of health care, has been a leading figure in this field since the 1970s. What does he think can be done to solve these problems?

Smedley, Brian D., Adrienne Y. Stith, and Alan R. Nelson, and the Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academies Press, 2003. Pp. 1-27. This is the executive summary of the most important report in the field to date. Do you accept their distinction between disparity and difference? Are the recommended solutions viable? Now nearly ten years later, has anything changed?

Byrd, W. Michael, and Linda A. Clayton. “Race, Medicine, and Health Care in the United States: A Historical Survey.” Journal of the National Medical Association 93 supplement (March 2001): 11S-43S. Byrd and Clayton provide an historical overview of the early intersections of race and American medical science and work to explore their legacies and continuing influence in our supposedly ‘postracial’ age. If race is not meaningful as a biological category, why is it nonetheless still so important in diagnostic, therapeutic, and epidemiological practices in the 21st century?

Learning Objectives:1. Recognize the types of disparities that exist according to race, gender,

geography, and other parameters.2. Understand the different factors (e.g., biology, financial incentives,

supplier-induced demand, arbitrary local variations in standard of care) that contribute to the disparities.

3. Brainstorm about different reforms and programs that could be implemented to reduce gender, race, geographic, or other disparities in treatment access and outcome, both in the United States and in global health.

Questionnaire:Please complete the questionnaire about the case vignettes before noon on

Wednesday.

Writing Assignment:You have several options for your writing assignment this week, including your home visit, this week’s cases, or the final project. Whichever you choose, please limit your answer to 500 words or less and email it to your tutor before noon on Wednesday.

(1) By now you should all have completed your home visits for Patient-Doctor 1. Did you encounter anything during your visit that raises questions of interest to social medicine? Do the perspectives and tools of social medicine

suggest anything that could be done to improve the patient’s living situation, access to health care, and health outcomes?

(2) Pick one of the case vignettes listed above and describe what factors might contribute to the disparity -- or is it a difference? The cases include references to the original report if you want additional detail.

(3) If you are working on the final project for 11/14-12/12, please send your tutor a paragraph describing your progress. How have you framed the question in a way that leaves you with a project that can be completed in the time available? What sources have you found? Are you having any trouble finding the material you need to make progress on your project? Is there anything we can do to help? Any work done only for course purposes does not require IRB approval. If you are using this project to get started on a SiM project, be sure not to do anything that would require IRB approval.

*** Whatever option you choose, you must, of course, still be prepared to discuss the required readings each week in tutorial and lecture. ***

Questionnaire (11/21):

Case 1: Is the disparity in pain management most likely:(a) appropriate, reflecting differences in pathophysiology or burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) other / not sure

Case 2: Is the disparity dialysis run-times most likely:(a) appropriate, reflecting differences in pathophysiology or burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) other / not sure

Case 3: Is the male-female disparity in coronary revascularization most likely:(a) appropriate, reflecting differences in pathophysiology or burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) inappropriate, and likely caused by underestimates of the lethality of CAD in women(f) other / not sure

Case 4: Is the black-white disparity in coronary revascularization most likely:(a) appropriate, reflecting differences in pathophysiology or burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) other / not sure

Case 5: Is the slight BMI disparity in coronary revascularization most likely:(a) appropriate, reflecting differences in pathophysiology or operative risk(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives

(e) other / not sure

Case 6: Is the geographic variation in coronary revascularization in the US most likely:(a) appropriate, reflecting differences in burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) inappropriate, and likely caused by local variations in medical opinion(f) other / not sure

Case 7: Is the US-Canada disparity in coronary revascularization most likely:(a) appropriate, reflecting differences in burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) inappropriate, and likely caused by local variations in medical opinion(f) other / not sure

Case 8: Is the Germany-Mexico disparity in coronary revascularization most likely:(a) appropriate, reflecting differences in pathophysiology or burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) inappropriate, and likely caused by local variations in medical opinion(f) inappropriate, the result of inadequate health care resources in Mexico(g) other / not sure

Case 9: Is the McAllen - El Paso disparity in Medicare spending most likely:(a) appropriate, reflecting differences in burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) inappropriate, and likely caused by local variations in medical opinion(g) a misleading result(f) other / not sure

Case 10: Is the black-white disparity in ECT treatment most likely:

(a) appropriate, reflecting differences in pathophysiology or burden of disease(b) appropriate, reflecting differences in patient preference(c) inappropriate, and likely caused by provider bias(d) inappropriate, and likely caused by financial incentives(e) explained by some other clinical factor (e.g., age, intensity of prior Rx, etc.)(f) other / not sure

ViolenceISM 2013: December 5th, 1:30-3:30

Overview:As we have discussed over the past several weeks, there are many problems that you will encounter as physicians that cannot be solved entirely with the confines of the patient-doctor relationship. Social, economic, and political forces generate the burden of disease, much of which could be prevented with upstream interactions. Health care delivery systems could be improved in ways that would improve patient outcomes (and physician satisfaction). Physicians can collaborate with community health workers, lawyers, and others to broaden the reach of medical interventions. Physicians will often have to grapple with issues that are inherently politicized in the United States or wherever else they work. The feasibility of a medical intervention will depend not just on the potential value of that intervention per se, but also on the broader social and political meanings and contexts of that intervention. How can clinicians best navigate such fraught terrain? This week ISM will take up three topics in which local, state, and national politics and social policies are an explicit consideration for health care and health policy. In lecture Anne Becker will describe how she encountered the problem of domestic violence against adolescent women in Fiji and will discuss why an effective response will need to draw on resources from beyond the health sector. Next, Eric Fleegler will describe how pediatricians in the United States have tried to put gun violence on the medical and public health agenda. In tutorial, we will look in more detail at the problem of gag rules, looking at two examples of government restrictions on patient-doctor communication. Tutorials can also set aside time to discuss the PD-1 home visits in more detail, looking specifically at any relevant issues for social medicine.

Key Concepts:knowledge base - social strategy - political willmedicalization and the “public health approach”politicization and “gag rules”

Cases:The readings describe two situations in which governments (federal or state) have put limits on how physicians and other health care providers can interact with patients:

(1) the Mexico City Policy (also known as the Global Gag Rule), about restrictions that accompany USAID funding for family planning programs.

(2) Florida’s 2011 Firearm Owners’ Privacy Act, which forbid doctors (targeting pediatricians in particular) from asking families about the presence of guns in homes.

Be sure that you understand the official justification of the policy, the broader political agenda of the groups that enacted the policy, the specific objections to the policy, and the broader political agenda of the groups that oppose the policy.

Readings:Lowe, Edward D. “Identity, Activity, and the Well-being of Adolescents and

Youths: Lessons from Young People in a Micronesian Society.” Culture, Medicine and Psychiatry 27 (2003): 187-219. This ethnography of teen-agers in a Pacific Island community demonstrates links among social change, intergenerational tension, and emotional distress. These, in turn, put teens at risk of suicide, violence, and other destructive behavior.

Hemenway, David, and Matthew Miller. “Public Health Approach to the Prevention of Gun Violence.” New England Journal of Medicine (23 May 2013): 2033-2035. Two researchers from HSPH describe how gun violence could be approached as a public health problem.

Palfrey, Judith S., and Sean Palfrey. “Preventing Gun Deaths in Children.” New England Journal of Medicine 368 (31 January 2013): 401-403. Drawing on their experiences as pediatricians (at Children’s Hospital and Boston Medical Center), the Palfreys use their personal and clinical experiences to advocate for gun control policy.

Population Action International. “How the Global Gag Rule Undermines U.S. Foreign Policy and Harms Women’s Health.” April 2013. Produced by an NGO dedicated to improving access to family planning services, this fact sheet critiques the family planning policies of the Reagan, Bush, and Bush administrations.

Also Posted:Becker, Anne E., and Arthur Kleinman. “Mental Health and the Global

Agenda.” New England Journal of Medicine 369 (4 July 2013): 66-73. The authors review the current state of the problems of, and responses to, mental illness and mental health on a global scale.

Fleegler, Eric W., Lois K. Lee, Michael C. Monuteaux, David Hemenway, and Rebekah Mannix. “Firearm Legislation and Firearm-Related Fatalities in the United States.” JAMA Internal Medicine 173 (13 May 2013): 732-740. Based on a review of gun-related deaths from 2007 to 2010, the authors reveal an association between more aggressive gun control laws and lower rates of gun-related homicide and suicide.

Swanson, Jeffrey. “Mental Illness and New Gun Law Reforms: The Promise and Peril of Crisis-Driven Policy.” JAMA 309 (27 March 2013): 1233-

1234. The author examines the pros and cons of various mental health policy proposals in response to the Newtown, CT shootings.

Kellermann, Arthur L., and Frederick P. Rivera. “Silencing the Science on Gun Research.” JAMA 309 (13 February 2013): 549-550. The authors discuss recurring efforts by Congress to discourage the CDC from studying gun violence.

Kuehn, Bridget M. “States Take a Public Health Approach to Curb Gun Violence.” JAMA 310 (7 August 2013): 46i8-469. An interview with Dr. Garen Wintemute, about politics and strategy for the campaign against gun violence.

Crane, Barbara B., and Jennifer Dusenberry. “Power and Politics in International Funding for Reproductive Health: The US Global Gag Rule.” Reproductive Health Matters 12 (2004): 128-137. The authors (who have a clear political agenda) discuss the politics of the Mexico City Policy, on the eve of the 2004 presidential election.

Learning Objectives:1. Understand how and why external political issues can impinge on

medicine -- or, from the opposite perspective, how and why physicians and public health officials try to medicalize contentious political issues.

2. Recognize ways in political interests can constrain physicians’ efforts to provide what they consider to be appropriate health care.

3. Develop strategies for navigating politicized clinical environments and advocating for policy change.

Questionnaire:Please complete the questionnaire before noon on Wednesday.

Writing Assignment:(1) Pick one of the two “gag rules” (the Reagan-Bush contraceptive policy or the Florida gun privacy policy), articulate a position for or against the policy, and develop a strategy that a physician could pursue in pursuit of that goal.

(2) By now you should all have completed your home visits for Patient-Doctor 1. Did you encounter anything during your visit that raises questions of interest to social medicine? Do the perspectives and tools of social medicine suggest anything that could be done to improve the patient’s living situation, access to health care, and health outcomes?

(3) If you are working on the final project for 11/14-12/12, please send your tutor a progress report. What is the most interesting thing that you have figured out about your topic so far? Have you narrowed your scope enough

so that you have a project that you can finish in the next week? Have you found the sources that you need? Is there something you are trying to figure out that has left you stumped so far? If you are having any problems, now is the time to get advice from your tutor or other course faculty.

*** Whatever option you choose, you must, of course, still be prepared to discuss the required readings each week in tutorial and lecture. ***

Questionnaire (12/05):

1. Many laws regulate behaviors that have the potential to affect health, including smoking laws, drug and alcohol laws, seatbelt laws, speed limits, helmet requirements, among many others. Should governments (federal, state or local), regulate firearms in the name of public health?(a) No laws should regulate firearms(b) Yes, but in a very limited way (e.g., age limits for purchasing)(c) Yes, there should be a range of laws to regulate the kinds of guns and ammunitions that are sold, where and how they are sold, and how they must be stored in homes(d) Firearms should be banned from the U.S.

2. Is gun violence a public health problem?(a) It is a limited problem that should be left alone by public health officials(b) It is a moderate problem worthy of local public health interventions(c) It is a significant problem worthy of nationwide attention and interventions

3. How should gun violence be treated within the medical system? (a) Limited involvement, e.g. gun injuries should simply be treated by appropriate medical interventions when they occur(b) Gun safety should be handled as a primary care issue by pediatricians, since children are at particular risk of accidental firearm injury (e.g., pediatricians should discuss firearms with families and provide advice safe ownership and storage)(c) Gun safety should a routine part of primary care for all patients, children and adults//4. Should research about firearms and health be performed?(a) There is no need for medical or public health research about firearms(b) Research on firearms might be valuable, but it should not be funded by the federal government (e.g., it should rely on private and philanthropic funding)(c) The government has a responsibility to fund research about firearms, as it does about other threats to health and safety.

*** keep this as a placeholder until final decisions are made about MH ***Global Health Strategy, Part 2: NCDs and Mental Health

ISM 2013: December ***, 1:30-3:30

Overview:Last week we began a discussion of challenges in global health. Remember, the goal here is not to master the details of health care in foreign countries. Instead, the goal is to apply what you have learned this semester about social medicine to understand the challenges we face and to develop innovative solutions. The problems of disease and health care overseas exhibit strong parallels to the problems of disease and health care in Boston. As a result, experiences in one setting can inform strategies in almost any other. As you analyze the problems presented in the cases and readings, recall the model, developed by Julius Richmond and Milt Kotelchuk, that Carole Mitnick described in her lecture: knowledge base, social strategy, and political will. Presented with a specific health problem, you often need to work on each of those three fronts to make progress towards a solution. Many of the cases involve questions of priority setting. Since the days of tropical medicine, health programs have focused on contagious diseases. Non-communicable diseases (NCDs) and mental illness have been neglected and under-funded. There is growing recognition that this is no longer appropriate (coronary artery disease, for instance, is now the leading cause of death in most countries worldwide). What can be done to alleviate the disparities in funding and attention? Paul Farmer will launch the class with a discussion of his work, especially the expansion of his focus beyond HIV and TB to include cancer and other NCDs. Tutorial will examine several cases that grapple with how to set priorities for mental health care, and for NCDs more broadly. Next week Anne Becker will describe her experience with global mental health policy.

Key Concepts:burden of diseasesetting health care prioritiesno health without mental health

Cases:1. As an advisor to a Ministry of Health in a low-income country, you are asked to develop community-based mental health services for youth. Your budget is very limited. In meeting with various stakeholders, one local expert recommends the development of a “center of excellence” for the specialized management of severe mental disorders. Another recommends a school-based mental health program that teaches teachers how to support youth and families with mental health problems. An influential local community advocacy group for the mentally ill suggests a faith-based

prevention approach that integrates education about mental health into the church and traditional healer systems.

2. Working as a responder in a post-disaster setting in a low-income country, you collaborate with a team of dedicated local clinicians who undertake a qualitative needs assessment of local practices, beliefs and priorities for mental health. Prior to the disaster there were no “formal” mental health services, but there does exist an extensive traditional healer network. Traditional healers themselves acknowledge that they can only treat certain kinds of mental disorders, and report being open to the addition of more “formal,” health-center based services. The needs assessment indicates that people in the community would like services focused on care for depression. However, your efforts are criticized by some academics who characterize your work as “neo-colonial”: specifically, it imposes Western concepts of mental health and illness on local people. They propose starting with more research to better understand local concepts of illness.

3. As the medical director of an international NGO responding to a disaster in a low-income country, you are driving and come across a naked man lying in the road about to be stoned by a crowd who believe he is possessed by spirits. You surmise that the man is mentally ill. Concerned, you bring the man to the psychiatric hospital in the capital city, several hours away by car. When you arrive, you realize: (a) conditions at the hospital are deplorable; (b) better treatment is not available elsewhere; (c) if you leave the man at the hospital he is unlikely to receive adequate care, and he might never find his way back to the community where you found him.

4. As the director of an international NGO, your vision is to set a new standard for the delivery of integrated health care for the most vulnerable populations. The organization has been working to develop interdisciplinary health services that address the burden of illness, help the most vulnerable people, and are compatible with the health systems and values in the countries and communities where it works. Traditional health delivery programs typically focused on infectious diseases such as TB and HIV. New programs focused on maternal and child health, surgery, cancer, heart disease, and mental health have emerged recently; these place a financial strain on the organization which, coupled with the current recession, limits the ability of the organization to expand its services. The organization asks you to submit a new strategic plan that reflects the strong arguments that exist for both hospital- and community-based approaches.

Also recall some relevant cases discussed earlier in the course:

[9/13]: The director of a community health center / the Secretary of Health and Human Services / the Director of the National Institutes of Health tries to

match its services to various measures of the burden of disease in the community.

[10/25]: John, 24M with moderate depression; non-compliant with fluoxetine; comes to clinic seeking a prescription for Lexapro after seeing an advertisement.

[10/25]: Jennifer, 25F with schizophrenia, non-compliant with haloperidol, requiring frequent hospitalizations.

[10/25]: Kelly, 44F, homeless, with alcohol abuse and tuberculosis. You worry that she will not stay sober or complete her course of isoniazid.

[10/25]: Miguel, 10M, evaluated to rule-out ADHD. Parents blame the behavior problems on the school and their recent move from the Dominican Republic.

[10/25]: Eleanor, 13F with obesity and depression. Her mother, who also struggles with both diseases, refuses referrals for Eleanor to MH services.

[11/15]: A 2011 study found that black patients were less likely to receive decisive therapy for depression (i.e., ECT) than white patients.

[11/29 & 10/11]: The Vietnam Ministry of Health tries to improve patients’ access to opioid analgesia.

[11/29]: Mental health providers in Aceh and Haiti try to create health care services to manage the burden of acute-on-chronic trauma in the populations after years of civil strife and natural disaster.

[11/29]: The Obama Administration struggles in 2009 to allocate funding among PEPFAR, maternal and child health, and other global health priorities.

[11/29]: An NGO sets out to define priorities for its ongoing efforts to improve health care in developing countries. It proposes five priorities: (1) HIV/AIDS, (2) maternal mortality, (3) pediatric care, specifically an effort to end child malnutrition, (4) access to surgery, and (5) improved access to care for acute and chronic diseases. Many important diseases, e.g., tuberculosis, are left off the initial list.

Readings:Frenk, Julio. “Reinventing Primary Health Care: The Need for Systems

Integration.” Lancet 374 (2009): 170-173. Frenk (dean of HSPH) provides a framework for understanding challenges facing global health. What does he mean by the unfinished agendas of infectious

disease and the emerging challenges of non-communicable disease? What is his vision for health systems strengthening?

Birbeck, Gretchen L. “The 2011 UN General Assembly on Noncommunicable Diseases: How Neurologic Disorders Got Left Out.” Neurology 77 (2011): 2067-2069. What are the four diseases and four risk factors at the core of the recent UN summit on NCDs? Birbeck describes a widely felt concern: that the nervous system (both neurological and psychiatric) got left out. Why did this happen? What needs to be done in response?

Miller, Greg. “Who Needs Psychiatrists?” Science 335 (16 March 2012): 1294-1298. Though focused on Indonesia, this article describes problems common throughout the developing world (and even much of the United States): a large burden of untreated mental illness and a lack of trained providers. What are possible solutions? The article describes efforts (including the work of HMS’s Byron and Mary-Jo Good) to train community health workers to provide basic psychotherapy and psychopharmacology.

Watters, Ethan. “The Americanization of Mental Illness.” New York Times, 10 January 2010. Globalization has influenced not just commerce and disease, but also diagnostic categories. Watters describes how western diagnostic categories have been adopted with increasing enthusiasm on a global scale. What are the pros and cons of this development? What would Watters want done differently?

Learning Objectives:1. Understand the reasons for setting priorities for global health policy, and

the inevitable consequences of doing so. Is it possible to prioritize one set of diseases without exacerbating the neglect of others?

2. Understand the reasons why mental health has traditionally been neglected by both national and global health policy, from the challenge of quantifying the burden of disease to the problems of stigma and other health priorities.

3. Strategize about how to develop an integrated health policy, one that takes seriously the full burden of disease while remaining cognizant of the inevitable limitations of funding, human resources, and political attention.

Questionnaire:Please complete the questionnaire by noon on Wednesday.

Writing AssignmentPlease write a 500-word response to one of the two prompts below -- and be sure to make good use of the readings. If you are working on a final project,

see the instructions about a progress report. Regardless of which of these three options you choose, submit your response to your tutor by noon on Wednesday.

(1) Pick one of the cases above and describe what you would do. What strategy would you pursue? How would you make the case that your choice is the right one? How might you mobilize the social resources and political support that you would need in order to succeed?

(2) Describe some of the factors that make mental illness a particular challenge for global health policy. What strategies might contribute to progress towards a solution?

If you are working on the final project for 11/15-12/13, please send your tutor a paragraph describing your progress. By now you should have a well circumscribed project that can be completed in the time available. You should have found sources that provide the background material you need. If both of these have happened, please describe your progress. If you are having trouble with one or both tasks, describe the problem so that your tutor can help troubleshoot. Any work done only for course purposes does not require IRB approval. If you are using this project to get started on a SiM project, be sure not to do anything that would require IRB approval.

*** Whatever option you choose, you must, of course, still be prepared to discuss the required readings each week in tutorial and lecture. ***

Questionnaire (12/***): Global Health Strategy Part 2: NCDs and MH

Case 1: After learning more about the three proposals, where would you initially invest your scarce resources?(a) A “center of excellence” for psychiatric care.(b) A school-based mental health program that relies on teachers to provide care.(c) A faith-based approach that integrates education, religious institutions, and traditional healers.

Case 2: In response to the critique of neo-colonial psychiatry, would you:(a) Proceed with the treatment program, relying on western diagnostic categories and treatment protocols.(b) Delay the treatment program so that you can more fully understand local conceptions of mental illness and design appropriate treatment programs.

Case 3: After realizing the limitations of existing psychiatric facilities, would you:(a) Leave the man at the hospital.(b) Return the man to his community.

Structural CompetenceISM 2013: December 12th, 1:30-3:30

Overview:

In this last week of the course we look backwards and forwards. What are the great challenges and opportunities for the 21st century? The basic challenges are clear, as can be seen by looking at the burden of disease and its social determinants. How best can these be overcome? That requires clear thinking about value, efficacy, health care delivery, and the social determinants of treatment access and outcome. How can you, as students and future doctors, contribute? This course has equipped you with the tools of social medicine. The challenge for you is to figure out how to apply what you’ve learned to the challenges we face. As you think about the looming health challenges, recall the model developed by Julius Richmond and Milt Kotelchuk that Carole Mitnick described in her lecture: knowledge base, social strategy, and political will. Presented with a specific health problem, you often need to work on each of those three fronts to make progress towards a solution.

Paul Farmer will begin the class with a lecture about two of his recent projects: health systems strengthening in Rwanda and the global cancer initiative. Both project demonstrate how individual physicians, by collaborating wisely (with other physicians, institutions, governments, and funders), can bring about real change not just in health care, but also in the health status of populations. In the second hour, we will offer some closing thoughts. Jen Kasper will share her perspective on health care in Boston and abroad. David Jones will then talk briefly about one organizing principle, “structural competence.” If cultural competence asks you to understand patients’ “culture” to understand their illness experiences, structural competence casts a wider and deeper net, focusing on structural violence as the underlying problem. Only by analyzing the structures that produce the problems of disease and imperfect health care can we work to design better health care solutions.

Key Concepts:burden of diseasesetting health care prioritiessstructural violencecultural competencestructural competence

Cases:

We have one new case. You should also revisit cases from throughout the course in search of the cross-cutting themes and concepts.

[new] As the director of an international NGO, your mission is to set a new standard for the delivery of integrated health care for the most vulnerable populations. The organization has been working to develop interdisciplinary health services that address the burden of illness, help the most vulnerable people, and are compatible with the health systems and values in the countries and communities where it works. Traditional health delivery programs typically focused on infectious diseases such as TB and HIV. New programs that focus on maternal and child health, surgery, cancer, heart disease, and mental health have emerged recently. These new programs place a financial strain on the organization which, coupled with the current recession, limits the ability of the organization to expand its services. The organization asks you to submit a new strategic plan that reflects the strong arguments that exist for both hospital- and community-based approaches.a[9/5] Santiago, 8M in Dorchester, has repeated ED visits for asthma flares.

[9/12] The director of a community health center / the Secretary of Health and Human Services / the Indian Ministry of Health / the Director of the National Institutes of Health tries to match its services to various measures of the burden of disease in the community.

[10/3] A cardiologist decides that she will no longer see patients who continue to smoke.

[10/3] A health insurer reviews raises premiums for people with high risk behaviors, including overweight, contact sports, unprotected sex, cigarettes, surgeons who work in communities with high rates of HBV/HCV, bicycle riding in urban areas, physicians who work in developing countries.

[10/17] Breast surgeons, radiologists, and patient advocates protest when the United States Preventive Services Task force recommends that screening mammography not be used routinely for women in their 40’s.

[10/24, 11/7] Mary, 37F in Roxbury, remains sick one year after diagnosis with AIDS.

[10/24, 11/7] Migeul’s parents reject a recommendation from his teacher and doctor that he start stimulants for ADHD.

[11/14] Seven years after WHO changed its policy and began to recommend treatment of MDR-TB, fewer than 1% of patients receive adequate treatment.

[11/14] The Obama Administration struggles in 2009 to allocate funding among PEPFAR, maternal and child health, and other global health priorities.

[11/21] Even though Canadian patients are less likely to receive coronary revascularization after an MI than US patients, one-year mortality rates are identical.

[12/5] Florida’s 2011 Firearm Owners’ Privacy Act forbids doctors from asking families about the presence of guns in homes.

Readings:Farmer, Paul E., Cameron T. Nutt, Claire M. Wagner, Claude Sekabaraga, Tej

Nuthulaganti, Jonathan L. Weigel, Didi Bertrand Farmer, Antoinette Habinshuti, Soline Dusabeyesu Mugeni, Jean-Claude Karasi, and Peter C. Drobac. “Reduced Premature Mortality in Rwanda: Lessons from Success.” British Medical Journal 346 (2013): f534.

Horton, Richard, and Selina Lo. “Investing in Health: Why, What, and Three Reflections.” Lancet (3 December 2013): 1-3. The editors of Lancet reflect on the current state of global health policy, as reflected in the major report just published in Lancet.

Kim, Jim Yong. “Time For Even Greater Ambition in Global Health.” Lancet (3 December 2013): 1-2. Kim, formerly a course director of ISM and now president of the World Bank, lays out a bold vision for the future of global health.

Berwick, Donald W. “To Isaiah.” JAMA 307 (27 June 2012): 2597-2599. This piece made a cameo on the syllabus in the Porter and Lee week (10/10). It is worth re-reading again, as a vision of the road ahead. Berwick describes many challenges facing health care: what are the opportunities and obligations for physicians?

Also Posted:Jamison, Dean T., Lawrence H. Summers, George Alleyne, Kenneth J. Arrow,

Seth Berkley, Agnes Binagwaho, Flavia Bustreo, David Evans, Richard G.A. Feachem, Julio Frenk, Gargee Ghosh, Sue J. Goldie, Yan Guo, Sanjeev Gupta, Richard Horton, Margaret E. Kruk, Adel Mahmoud, Linah K. Mohohlo, Mthuli Ncube, Ariel Pablos-Mendez, K. Srinath Reddy, Helen Saxenian, Agnes Soucat, Karene H. Ulltveit-Moe, and Gavin Yamey. “Global Health 2035: A World Converging within a Generation.” Lancet (3 December 2013): 1-58. This report, by a who’s who of leading figures in global health, offers a follow up on the World Bank’s influential 1993 World Health Report.

Farmer, Paul E., Julio Frenk, Felicia M. Knaul, and others. “Expansion of Cancer Care and Control in Countries of Low and Middle Income: A Call to Action.” Lancet 376 (2 October 2010): 1183-1193. How do the

authors make the case to expand cancer care? Do they see a choice between cancer and other priorities, or just a choice between taking on cancer, or not -- and why does this matter?

Prince, Martin, Vikram Patel, Shekhar Saxena, Mario Maj, Joanna Maselko, Michael R. Phillips, and Atif Rahman. “No Health Without Mental Health.” Lancet 370 (8 September 2007): 859-877. These authors offer a call to action for mental health care. How does their strategy seek to overcome the stigma and neglect traditionally associated with mental illness?

Frenk, Julio. “Reinventing Primary Health Care: The Need for Systems Integration.” Lancet 374 (2009): 170-173. Frenk (dean of HSPH) provides a framework for understanding challenges facing global health. What does he mean by the unfinished agendas of infectious disease and the emerging challenges of non-communicable disease? What is his vision for health systems strengthening?

Learning Objectives:1. Review and consolidate the material we have discussed in the course,

especially efforts to ground health policy in an understanding of the burden of disease.

2. Recognize the key health challenges facing the United States and other countries in the 21st century, and the ways in which social medicine can contribute to possible solutions.

3. Appreciate the limitations of concepts like cultural competence and the potential of concepts like structural competence.

4. Engage with the opportunities that exist for research and practice in social medicine and global health exist at Harvard Medical School.

Questionnaire:None. However, we really do want you to give the final course evaluations serious thought. Be sure to comment on readings (favorite and least favorite), case vignettes, questionnaires, lectures, tutors, etc. All feedback is welcome. This feedback will be of immediate practical value because HMS has embarked on a major curriculum reform and hopes to have a new curriculum in place by fall 2015. Since major planning will take place over the next 6 months, your feedback will influence our proposals for the possible roles of social medicine and global health in the new curriculum.

Writing Assignment:Please write a 500-word response to one of the two prompts below. If you are working on a final project, see the final instructions below. Regardless of which of these three options you choose, submit your final work to your tutor by noon on Wednesday. If you need extra time for a final project, you may

negotiate extensions with your tutor; you should, however, submit well before the genetics final exam.

(1) Imagine yourself as a resident in five years (pick a likely specialty -- medicine, pediatrics, orthopedics, etc.). What problems do you think you will encounter that will benefit from the insights of social medicine? Can you imagine ways of putting to good use the material we have discussed in this course?

(2) Is there a topic that this course really needs to discuss? If so, describe the topic and make a case for why it is important for social medicine.

Final Projects: For those of you working on final projects, please submit them by 12/11 or contact your tutor about a reasonable extension. When you do submit, be sure to provide a bibliography and appropriate citations. The goal is to write something thoughtful, interesting, scholarly, and useful. While it might be possible to do this in as few as 3-4 pages, past experience generally suggests that 6-10 pages is a reasonable target. You are, of course, welcome to do more extensive work. Final details can be negotiated between you and your tutor. Feel free to contact any of the tutors, or other DGHSM faculty, for advice and guidance.