As a doctor in training, we often hear “horror stories” of the patient or patient’s loved one, who goes a little off the deep end when they receive an unfortunate diagnosis or a fatal prognosis. It’s a defense mechanism. It’s the patient’s way of trying to comprehend, “Why me?” They urgently seek an etiologic agent and subsequently try to bring it to justice. “It must have been that thing I ate that day when we ate at that picnic 7 months ago...it must be because the government poisoned the air in my neighborhood...I just read a study linking lightbulbs to my condition!” Absurd as some of this sounds, when anyone tries to answer the question, “ Why me?” we all come up with an amusing at times, but limitless array of answers.
However, as physicians we know that definitively pointing at a cause for a disease is nearly impossible and takes years of study. (For instance, it took decades to definitively link smoking to lung cancer.) Therefore, for the majority of suffering seen in the clinical setting, there is not one guilty culprit that we can lock up and ensure never causes harm again. On the contrary, there are usually many suspects, and sometimes these suspects even intersect on their path to causing disease. While this makes epidemiology pretty interesting (for epidemiologists), it is frustrating for patients. Similarly, in the court system, trials are long, and any suspect which leaves reasonable doubt of guilt is acquitted. While the suspect may be watched more closely, the victim cannot be prescribed an intervention to simply eliminate it.
This poses a problem for patients and all providers. This means illness is not just; by definition, it is not fair. Justice, or the concept of fairness, is what patients seek out though. They immediately ask themselves, “Why me?” “What did I do to cause this?” Numerous cultures blame disease on other factors that do not fit into the Western bio-medical model. Health is sometimes defined by you and your family’s good fortune and social status while disease might be caused because you dishonored your god or family. They link disease to a specific cause, and they explain symptoms as something you might deserve. They seek a way to explain it and make it fair. While we in the U.S. might not agree, what stands true is that across all cultures, we instinctively strive to pin down the cause of disease because we desperately want it to be fair. We want to lock the culprit away or at least prevent any reason for a disease-causing agent to get us. Furthermore,when both patients and providers feel justice is unobtainable, we can become anxious, depressed, angry, isolated, and suicidal.
Alternatively, I have also seen the lack of fairness surface as symptoms just as I have seen symptoms manifest in a quest for justice. I saw it in court when I was 12. One of my family members suffered GI symptoms, headaches, lack of sleep and anxiety when things were just not fair and out of her control.
I wanted to understand this, and maybe that experience propelled me into attempting to understand social justice and its effects on health.
Why do some places get Tb, HIV, and cholera, while other places do not? Why do poor people get certain diseases, and rich people simply don’t? Why in the U.S. are some areas healthy and some not? What unfairness happened to this person that made their health so poor?
Granted, I understand there is personal responsibility involved in health, but that goes for people with the education, resources and belief system that certain behaviors do in fact increase your health and prevent disease. Most importantly, people who take personal responsibility for their own health know they are worthy of good health in the first place and know they are capable of leading healthy lives. For those that do not lead healthy lifestyles, poor education, lack of resources, poor self-efficacy and lack of feeling worthy all contribute to poor outcomes. Lack of resources and poor education is what we can control to a large extent at a population level, where self-efficacy and self-worth can be targeted at an individual level. Either way, isn’t it just unfair that someone might not know about clean water and have access to it, and is subsequently why they are exposed to cholera? Isn’t it just as unfair that an adolescent might not have anyone to reinforce their self-worth and teach them healthy habits so that they might learn to lead healthy and happy lives? It is this basic unfairness leading to poor health that sets me off.
To summarize, social justice determines health outcomes on a population level, and fairness at an individual level heavily influences the health of that individual.
At the Survivors of Torture and Trauma Project, a project of a refugee resettlement agency I am currently interning at, I see this everyday. For example, both mental and physical health symptoms are not alleviated until a rapist is put to justice. For my clients, symptoms will not go away until they fully realize asylum, and they feel safe from the treacherous circumstances of which they fled. Sometimes asylum is granted, and an ounce of fairness is reached, although it really does little to compensate for the trauma endured. However, healing must progress otherwise, despite the lack of fairness. In some cases, clients can at least find refuge, a place where healing can start while true justice might never be achieved.
Today I went to court again - flashback from half my life ago. I was sitting as the case manager with my client’s three adolescent girls. I could see it. The mother’s testimony through the interpreter, the roundabout questioning common for those fluent in the legal system and foreign to me.
In medicine, if I want to know something, I look it up or I simply ask what I want to know from a patient. In the courtroom, if you want to know something from a respondent, apparently, the “best” way is to fire twenty questions that kinda not really narrow in on what you want the person to say, and if they don’t say exactly what you want to hear, well...we will see what happens when the verdict is made.
Confusion, unfairness, trauma, tears. No one should have to see the strongest person you know, your hero, your mother, go through that. It’s not fair. It’s not fair to the mother, and it’s not fair to the daughters, but it happened today.
As future physicians, we encounter injustice everyday, and we must fight it.
How do you fight injustice? You advocate.
Because reaching justice by finding criminals and removing them alleviates symptoms and disease, whether it be the pneumonia causing bacterium, poverty (an etiologic cause of numerous ailments), or a trauma- causing suspect. You advocate for disease causing agents' removal so that they cannot cause more harm and damage.
However, while we must advocate, we also must strive to heal despite lingering injustice.
For those whom injustice has already violated, we need to build that patient or population up stronger and help them develop their own resilience so they can find their own justice within themselves and begin to heal.