“Medicine is a social science and politics is nothing else but medicine on a large scale." - Rudolph Virchow
When Beth was diagnosed with diabetes, her doctor provided what many would call great care. He followed the correct protocols, started her on Metformin—a successful and inexpensive diabetes medication—and referred Beth to diabetes education. After three months of medications and diet changes, Beth’s blood sugars remained dangerously high. Her doctor decided to offer Insulin, a stronger medication that would require injections rather than Metformin’s pill form. She left the clinic with her new insulin prescription and planned to follow up in a month.
There was only one problem. Beth didn’t have a refrigerator.
Refrigerators aren’t often incorporated into medical education. Rather, future doctors in American medical schools are successfully equipped with disease mechanisms and pharmaceutical knowledge. Less often taught are deeper details—insulin needs to be refrigerated—and the important question prior to insulin prescription: “Do you have a refrigerator?” In Beth’s case, that question was never asked.
The notion of the lost refrigerator is both a symptom and symbol of what medical education has neglected. Medical school focuses on biomedicine, in other words, the drugs and bugs. Social medicine, on the other hand, remains largely absent from medical education.
Like many academic topics the term “social medicine” requires space for definition. Social medicine is the study and practice of medicine which takes into account the structural causes of disease—which can range widely from historical trauma to colonialism that decimated large swaths of lands and nations. At a simplistic level, social medicine looks at the risks behind the risks of disease. It unapologetically asks “why” people become sick. It then asks “why” again, and again, until the roots of disease are uncovered. In comparison, the biomedical approach stops at insulin while social medicine moves beyond the refrigerator.
In American medicine it’s not uncommon to find one step solutions, often in instructive form. Take this drug for that disease. Change this behavior for that condition. To limit medicine to such a surface understanding harms medical care. More importantly, such an approach robs patients of a just health care system and a doctor who truly advocates for her patients. Medicine without the social components displaces patients of their humanity and dilutes the patient role to their behaviors, and, increasingly so, entries on billing statement.
Perhaps the best way to understand social medicine are examples of its utility. If you were to ask Dr. Ed Ehlinger, Minnesota’s Commissioner of Health, his take on the most important public health intervention you might be surprised. Germ theory? Discovery of Penicillin? Both would be incorrect. The greatest intervention of America’s health came in the early 19th century, according to Ehlinger. After its implementation, maternal mortality rates rapidly declined. Still guessing? The answer is women’s suffrage.
The 19th Amendment did more for women’s health than any other intervention imaginable. During WWI, as lives and resources were consumed, there were more American women who died in child birth than American men who died in war. Up until that point, the U.S. had benefited from economic booms and the nation’s health had follow suit. Maternal health, however, lagged behind other metrics. When women and their previously hushed voices were brought into the political system it’s no surprise that women’s health improved. The electorate had doubled, and maternal mortality plummeted.
So is social medicine the same as public health? Well, no. While social medicine pulls from public health disciplines, it seeks to unpack the power structures of politics, structural violence, and systems that stratify patients and nations creating disparities in ability to pay for drugs or access clinics and hospitals. Social medicine recognizes that health is fundamental, a right that is central to human potential and wellbeing. Social medicine's objective is health equity, and it offers tools to reach that end.
With this in mind, let’s try a social medicine approach for Beth's case.
Why did Beth not have a refrigerator? She was recently evicted from her apartment and now staying at shelters. Why did she have to stay at a shelter? Low income housing was unavailable. Why was low income housing unavailable? And the questions continue through the structural roots of disease. One influence of Beth’s current health status could cite political ideology, specifically, the Reagan administration austerity policies, which, from 1980 to 1985, cut the affordable housing budget by 23 billion—which eliminated proposals for over 170,000 low income housing units—and placed stable housing for poor Americans in limbo. Such questions reveal deeper questions (and solutions) rather that a brief sentiment that the patient didn’t take her medication.
While physicians shouldn’t be expected to shoulder all burdens of political injustice and structural failure, a doctor should be able to practice within the context of the community in which they live. This means thinking outside of biomedicine. To achieve this, medical institutions must recognize the value and urgency of incorporating social medicine into curriculum. Even topics like refrigerators.