Doctors for America Blog

Blessed are the Peacemakers

Thu, 23 Feb 2012 10:38:27 -0500

If you ever wondered just how ridiculous election year debates can get, look no further than the continued row over the President’s compromise on access to birth control. President Obama may have gone just too far this time, having been much too reasonable and understanding of the opposition. Last week, in the midst of shrill cries about religious liberty, the President announced that he would protect the health insurance reform that guarantees access to free birth control, but that out of concern over Catholic Church doctrine, insurance companies, not Church-affiliated employers, would pick up the tab.

And it’s not a bad tab to have to cover. It turns out that providing all the standard FDA approved contraceptive services generates no net cost to insurance plans. Prevention saves money. So forget the arguments that this is somehow an accounting gimmick – that the Pope and other opponents of women’s rights will actually end up paying for The Pill because of cost shifting. It’s simply not true.

And yet the religious right and some cynical Republicans want to continue to have this fight, hoping for an election year advantage by pitting the President against religion. Pending legislation in the House and Senate, and even some state legislatures, will move to allow ANY employer to shirk contraception coverage based on personal beliefs. In fact, to help gin up the cause for this, House Republicans actually held a hearing on this “attack on religious liberty” featuring a bunch of male clergy who happened to be in favor of restricting contraception, while not a single woman in favor of contraceptive access was allowed to speak.

Really? Do we want ANY single self-professed religious person defining for his employees what is and is not an allowable health care expenditure? Would these same bishops and rabbis be ok with their congregations working for a Jehova’s Witness who refused to cover blood transfusions in the company insurance? What if you work for a Christian Scientist? Shall it be permissible to deny health care coverage all together just because someone’s boss thinks she should be able to pray her illness away?

No, the fact is that religious liberty does not mean that we get to impose our beliefs on everyone else. In this society, in our Republic, we make democratic decisions about how to balance the public good against individual rights. As a result you can’t marry multiple wives, you pay taxes even though much of that money goes to funding wars and other objectionable projects, and, yes, employees of religious charities get their preventative care like everyone else.

In exchange, our society lets all religions worship as they want, teach their theology openly, even discriminate on hiring in certain contexts. But when the faithful leave their cleric to see a doctor, their treatment is up to them as individuals. A patient’s insurance coverage ought to reflect her needs, not the dogma of her faith community, or, least of all, the whims of her employer.

What's Ahead for Healthcare Reform in 2012?

Tue, 21 Feb 2012 19:30:00 -0500

Doctors for America Newsletter February 2012: Policy Perspective

The Affordable Care Act of 2010 will celebrate its second birthday in March. According to the Kaiser Family Foundation, 43 of the 46 reforms scheduled by the Affordable Care Act to be in place in 2010 and 2011 are already in effect. We’ve seen coverage provided for young adults, a filling of the "donut hole," restraints on premium increases and historic opportunities for practice innovation. So what should we expect in 2012?

There will be continued work on payment reform and practice transformation at the Federal level, but much of the action is also now happening at the State level, around issues like insurance exchanges and determining essential benefit packages. This is where doctors from the community can have a powerful voice. Sign up for DFA’s One Million Campaign and find the resources you need to make yourself heard.

There will be further attempts to defund the Affordable Care Act through a planned 27% Medicare cut also known as the SGR. The next vote in Congress will be February 28^th, and it won’t be the last. DFA opposes these cuts and is standing firm in its position that we need to innovate, not amputate, when it comes to healthcare.

Look to the Supreme Court March 26^th through 28^th. The court will hear challenges to the constitutionality of the Affordable Care Act, with a ruling likely later in the spring. DFA will be planning events and activities around this date to highlight the issues at stake.

The CMS Center of Innovation has announced the first group of Innovation Advisors – seventy-three innovators from around the country who are on the cutting edge of change. You may recognize some of the names.

Doctors for America Updates

Tue, 21 Feb 2012 19:30:00 -0500

Doctors for America Newsletter, February 2012

The One Million Campaign Has a Spectacular Launch!

In 2012, DFA doctors and medical students will educate one million of our fellow colleagues and the general public about health care reform and the ACA. On Sunday, January 16^th, Doctors for America launched this One Million Campaign, surrounded by the inspiring message of Martin Luther King Day and the background of the National Mall in Washington, D.C. The physicians and medical students from across the nation that participated in the campaign’s kick-off were led by Zeke Emanuel, renowned bioethicist and health policy expert, and the day provided a dramatic jump start. It started with an appearance by Dr. Emanuel on Morning Joe, and a DFA march to the Washington Monument, followed by a jog around the mall. Participants then fanned out over the mall to distribute hundreds of flyers and obtain signatures of support. Campaign sparks ignited elsewhere across the country. Doctors rallied and marched in Dayton, and community forums are being organized from New England to California.

The DFA website provides a wealth of resources to engage physicians in the campaign, whether it be through informational presentations or op-ed letter writing. Physicians from 36 states have joined the campaign so far. Those of you who have signed up can add your name to the map of participants, download a copy of the “Declaration of Support” for signatures, receive training materials for presentations, log your activities or donate. If you haven’t signed up yet, it is quick and simple! Watch for frequent updates on our actions and progress as this campaign to “engage, educate and empower” spreads throughout the membership and across the country.

Policy Updates: Over 1300 doctors and medical students speak out on access to contraception

Tue, 21 Feb 2012 19:25:00 -0500

Doctors for America Newsletter, February 2012: Policy Updates

Over 1,300 DFA Members speak out on access to contraception. The ACA calls for the provision of preventive services, including contraception coverage, without copays to all covered individuals. Last month HHS Secretary Sebelius announced that exemptions for this coverage would be allowed for churches when they purchase insurance for their employees, but ruling that other religious organizations that make coverage available to their employees - such as hospitals and educational institutions - would not be exempt. This quickly erupted into an intense political firestorm , and DFA moved quickly to make our position clearly heard at the highest levels of government.

Physicians and medical students from all 50 states signed our open letter supporting accessability of contraception to all insured women. Our infograph was viewed over 100,000 times. Our willingness to speak out boldly and unequivocally on this issue has drawn the attention and appreciation of White House advisors as well as organizations such as Planned Parenthood, The National Women’s Law Center, and the Center for American Progress. The petition received wide attention from media outlets like MSNBC’s Hardball, The International Business Times, PBS and NBC affiliates, and across major blogs.

In response to the heated controversy President Obama last week agreed to concessions that will exempt some religious institutions from providing these preventive services, but safeguards have been put in place to make sure that the insurance companies will have to provide free contraceptive services to employees under separate arrangement.

Doctors for America is establishing its place in the world of organized medicine with its ability to quickly generate physician participation and public attention around the most contentious or controversial issues of health care policy. We are willing to take a public stand on issues that matter to our patients, and we know how to do it effectively. We will continue to push hard on the contraception issue and expand our reach with blog posts and letters to editors. And we will be heard.

Here is some of the press coverage we got:

National Media

MSNBC Hardball with Chris Matthews (showed and mentioned our petition)
Washington Post (mentioned our petition)
International Business Tribune: 70 Catholic Doctors Sign Petition Supporting Obama Birth Control Mandate

Local Media

Baltimore Sun Op-Ed (by Meghana Desale, Lorena Leite, Tatyana Lyapustina, Kathryn Miele, Amir Mohareb, Samuel Scharff, Naomi Rios and Katie Washington)
CBS affiliate in Florida (featuring Dr. Rashmi Murthy)
San Antonio Express-News Letter to the Editor (by Dr. Robert Luedecke)
SF Chronicle (quoted Dr. Claire Broome)
KIQI (Spanish-language talk radio, interviewed Dr. Laura Davies)
KOCO TV in Oklahoma City (interviewed Dr. Kathy Scheirman)
KIRO radio in Seattle, WA (interviewed medical student Natalie Hale)
Colorado Springs (interviewed Dr. Lila Rosenthal)
The Atlanta Journal-Constitution (front page article featuring Dr. Gayathri Kumar on 2/11 - print only)

Physicians in Action: January-February, 2012

Tue, 21 Feb 2012 19:20:00 -0500

Doctors for America Newsletter, February 2012: So who volunteers for leadership roles?

Physicians and medical students from across the country are stepping up to leadership roles in DFA. They each bring their own talents and motivation, as well as a shared passion.

Here are the members of the One Million Campaign National Leadership Team. The all-volunteer team is leading efforts to support Doctors for America members in organizing and educating people around the country and making the One Million Campaign a success!

Raag Airan (Data and Metrics Director) is a radiology resident at Johns Hopkins. He has been involved with DFA since 2010 as a blogger and on the policy team. "I do this to make sure health care reform moves forward to ensure a system that works for patients and their doctors, not against them."

Evan Saulino (Education Co-Director) is a family physician in Portland, Oregon. He joined the DFA Board in December, 2010 after leading successful physician advocacy efforts in Oregon for many years. "I am here because after having two patients die in 2006 due to lack of insurance, I decided it was time for me to do something about it."

Manisha Sharma (Education Co-Director) is a family medicine resident at Montefiore Medical Center in the Bronx. She has been a part of Doctors for America since early 2010 when she played a leading role in our Health Professionals March on Washington.

Scott Poppen (Policy Director) practiced primary care internal medicine for 25 years before retiring in 2011. He has been Utah State Director since 2009. "I believe that access to quality, affordable health care is a basic human right and work towards securing that right, already recognized in the rest of world, for the citizens of the U.S.; and towards eliminating the excessive health care costs, wastes, and inefficiencies which threaten the economic vitality of our nation and its citizens."

Anubhav Kaul (Recruitment Director) is a 4th year medical student from Ross University with a strong interest in Public Health. He joined the organization last year and is focusing on the recruitment effort. He is committed to improving health care delivery and ensuring quality accessible health care for all. Also, he is a die hard Boston sports fan.

Kate Prather (Materials Director) is a medical student at Georgetown University. She has worked with DFA since 2011 and helped to co-found the student Doctors for America group at the Georgetown School of Medicine. "I believe that health care is a human right and that physicians and medical students have an obligation to speak up on behalf of those without a voice."

Meghana Desale (Training Director) is a third-year medical student at Johns Hopkins. She has been involved with the organization since starting medical school by organizing events for membership and the public in Maryland and educating other medical students through presentations and webinars on the basics of the Affordable Care Act. "I believe that everyone has a right to access quality health care. We owe it to our patients and our profession to have a voice in the making and implementation of health policy."

Hahrie Han (Research Director) is the Sidney R. Knafel Assistant Professor of Political Science at Wellesley College and does research on political activism and political organizing. "I am committed to using my skills to building a more coherent, more equitable, and more accessible health care system."

The members of the team were joined by Liz Oler (Georgetown med student chapter president), Rita Nguyen (MA state director) and Shalini Pammal (Harvard undergrad who is building a pre-med college chapter!) in DC on January 14-15 for a 2-day intensive leadership training with the New Organizing Institute.

And more stories of physician activism across the country

Clarke Hinderleider (CA) and Joel Weddington (CA) are collaborating with local physician activists from the National Physicians Alliance to organize “town hall” events about healthcare reform in the Bay Area.
Dr. Maggie Kozel (RI) spoke at a community forum in Jamestown, RI, educating an audience of 40 people about the ACA . Local press coverage extended the reach to 5,500 readers.
Dr. Sultan Rahaman (FL) was an attendee at a "State of Seniors Health" roundtable discussion in Orlando, FL.

Discovering DFA: I Am Not Alone

Tue, 21 Feb 2012 15:25:00 -0500

Doctors for America Newsletter February 2012 Feature Story

I left a busy pediatric practice in 2001 to teach, to refuel, and to write about a health care system I viewed as growing increasingly dysfunctional. I felt compelled to write about the disconnect between what doctors are trained to do and what we are paid to do by short-sighted insurers, and about how health care is shaped more by strategic business decisions and pharmaceutical marketing than it is by medical science. But sitting at my laptop, typing away at a book chapter or a Huffington Post blog, I felt quite alone.

As I think back on the colleagues I have admired the most over the course of my pediatric career, what they all seemed to have in common was a solitary – almost private – idealism. When I finished my medical training back in the 1980’s, doctors were largely an apolitical lot, as if it was an unwritten code. The most dedicated physicians practiced as conscientiously as they could, always putting the patient’s interest first. The more dedicated they were, the less likely they were to talk about it. For my generation of doctors, political activism simply didn’t fit into our notion of who we were. The heroics of medicine passed quietly, in the day-to-day decisions of patient care.

The past decade has made that noble, solitary effort insufficient. Health care-for-profit and the growing political power of special interests has overpowered our ability to protect our patients’ interests one encounter at a time. Doctors who are passionate about providing affordable, quality health care for their patients feel isolated and overwhelmed – and too often defeated – if they are fighting a solitary fight.

One day, just about a year ago, I shared emails back and forth with a doctor from Virginia who edited the Doctors for America blog. He reposted a blog I had written about proposed Medicaid cuts, and that in turn sent me to the DFA website. What I found there were 15,000 doctors and medical students all dedicated to the notion of quality health care for all. Physicians were writing and speaking about and supporting the very same issues about which I cared so deeply. I found stories about rallies and petitions. I saw a picture of young doctors standing with President Obama at the White House. Grassroots physician activism was showing itself to be a powerful new tool for patient advocacy and health care reform. And there seemed to be as many forms of physician activism as there were members.

So I joined DFA’s blogging team, and last spring attended the first annual DFA conference in D.C. A few months ago I took on the role of editor of the DFA newsletter. My work for DFA has been meaningful and empowering because I can see the results. Our voices are being heard above all the rhetoric because what doctors have to say has always mattered, and what we say in unison cannot be ignored. Fighting for our patients should not feel like a lonely endeavor. It no longer does to me.

The Patient's Time

Tue, 21 Feb 2012 13:23:45 -0500

I recently worked a shift at one of the free, student run clinics here in Palo Alto. Compared to a previous shift a while back, today was quite calm with a manageable flow of patients. In fact, the number of volunteer hands far outnumbered the number of patients so I wondered if my services were even necessary.

Should I duck out early to go work on one of the four problem sets that I have due this week? Now that my time is strained, I must be a bit more selfish to keep everything streamlined and maximally efficient. So this is a waste of time, right? I should be focusing on my studies and come back another day when I can really get my hands dirty and get some clinical experience under my belt. These were some of the thoughts flowing through my mind as I sat idly for the first hour waiting to see my first patient.

Of course, as I notice upon reflection, all of my thoughts revolve around me, myself, and I. This is my precious Sunday and I have work that must be finished and I could be outside enjoying the day and…. the list inevitably grows longer with each passing second. But who is to blame? It took a whole heap of self-centeredness to get to this position and to have this opportunity in the first place. Everything involved in the preparation for medical school is necessarily a total preoccupation with oneself—my school work, my time, my goals, my future. So this is different. I feel a bit uncomfortable and anxious. But in reality, this is life so I had better adjust and embrace it.

We have switched roles. I am used to controlling my own time, but now time is in the driver’s seat. And this is not my time. This time belongs to the patient in the waiting room who is both anxious and hopeful for my arrival. And his time grips me forcefully, commanding me to obey. For I am now at his service and at the service of anyone who takes the brave step of coming into a free clinic in what is often a desperate search for care, compassion, and attention. How could my time possibly trump that of the patient. It would be a negation of the intrinsic morals of the profession to which I am now devoting myself.

And then, chart in hand with white coat buttoned, a step into the waiting room and make eye contact with the patient. Before I even have a chance to introduce myself, this temporary tug of war ceases; the patient wins and I helplessly submit as soon as I let go of my self-righteousness. Over the course of our exchange, a change of perspective to the patient’s point of view makes everything clearer. I imagine myself… in an unfamiliar setting, simultaneously ashamed and stressed by my loss of health insurance, in desperate need of a refill for my diabetes medication. I have nowhere to turn and no one to turn to for help. My wife does not speak English, yet she has come with me to this new world in hopes of a better life. And what do I give her in return? Nothing! I am unemployed and unable to provide for her and my two young sons. Up until the recession, I was successfully employed as a building contractor. Demand was high with the expansion of the tech companies here in Silicon Valley. I was in the driver’s seat, but now, three years later, I am on the ropes of financial ruin. I am ashamed, but I am fearful that if I do not seek help my condition will worsen. I am committed to caring for my health, but the financial stress of every day put health on the backburner. And now I am here, against my will, but seeking your help and guidance.

As these thoughts flash by—one by one in a jumbled order—I forget about myself. My time and energy meshes seamlessly with that of the patient. I am eagerly entangled in his story, full of want to know more and to understand how this condition came to be and how it affects his daily life. For a man who was in near perfect health for most of his life, a diagnosis of diabetes three years past was terrifying and upsetting. Not only is this a chronic condition that requires daily attention and management, but this is the evil culprit that broke his streak of good health. In a sense, this was a challenge to his independence and self-worth—a chink in the armor that exposes vulnerability. He does not want to be one of the 824,000 Californians or one of the more than 7 million Americans ages 45-64 with diabetes mellitus. Moreover, the pain of vulnerability is been exacerbated by the shame of unemployment and the inability to procure health insurance for him and his family. This idea of taking medicine seems almost unmanly. After years of contracting with pharmaceutical companies, he distrusts their motives and views the drugs they sell as profiteering scams. He refuses to become dependent on industrialized drugs, and has experimented with alternatives such as cinnamon to regulate blood sugar and garlic to lessen his blood pressure. But his stress levels remain high as his blood pressure affirms. Blood glucose levels are elevated, so despite his attempts at denial, he has made the hard first step of seeking care. I commend him.

Although he eventually acknowledges the necessity of a refill of Metformin and Cozaar, we enter into a fruitful discussion of lifestyle. He expresses a desire to be more physically active and we determine that a first step would be walking and playing with his two sons in the nearby park during the week. He explains how he has become more conscious of what he eats and focuses on eating smaller portions with everything in moderation. We talk about some healthy lower carb options and possible substitutes for some of the foods that he is already eating. Although the medications are critical at this stage, we both agree that lifestyle changes will be critical in the long run. In fact, his aversion to medicine may be a powerful weapon in his fight against diabetes because to save himself, he must commit to lifestyle change. He seems willing and excited to have guidance and encouragement. I am excited that I actually have knowledge and experience to bring to this situation. We feed off of each other’s positive energy as if we had been friends for years. As the visit closes, he is visibly elated and encouraged. In fact, we both are because we are both invested in his health.

In merely speaking with this patient, I remember why exactly I am traversing down this rocky road called medical school. Moments like these make it all worth it. I must remember this next time I am feeling stressed by my own to-dos and frustrated when time escapes my control. This is life, and in comparison to most of the patients that I will encounter, my position is pretty sweet. I must never forget this and remember to give each patient my best effort and attention because each patient is worthy of my best. As I progress in my clinical training, I intend to consistently remind myself that this is what I am working towards and each moment with a patient is not only practice…it is a privilege.

Smearing the USPSTF

Tue, 21 Feb 2012 13:21:09 -0500

The United States Preventive Services Task Force (USPSTF) is a federal committee composed of private sector experts in prevention and primary care. Its mandate is to make recommendations as to which preventive services are beneficial, which are usesless and which are harmful. Disconcertingly, there is a small but vocal oppostition to the USPSTF as embodied by an op-ed piece in the Wall Street Journal last week by Dr. Scott Gottleib.

Dr. Gottleib’s main argument against the USPSTF is that it sets too high a bar for evidence to demonstrate that a particular test or intervention is beneficial and that it is out of sync with conventional medical practice. At the same time, because its recommendations for preventive services must be covered by insurance companies, it represents an insidious power grab by the Obama administration.

This smear against the USPSTF is baseless for a number of reasons. First, the USPSTF recommendations are valuable precisely because the bar for the evidence is high. Primary care physicians know that these recommendations are built on a solid foundation of evidence and so when services are recommended, those graded A or B, we know that we should offer them to our patients to improve their health. Requiring that insurance companies cover these services at no cost to patients ensures that money is not a barrier to getting beneficial preventive services.

Second, ‘conventional medical practice’ is not synonymous with quality medical care. A study in the Annals of Internal Medicine published this month shows that 28% of physicians would screen women at low risk for ovarian cancer. This is despite the fact that no professional society recommends ovarian cancer screening and that the USPSTF finds that the potential harms outweigh the benefits. In general, some conventional practices not grounded in evidence are later found to be beneficial while others are later found to be useless or harmful. This uncertainty may not sit well with many but it is the reality of how medical knowledge unfolds.

Third, there is nothing wrong with health plans dropping coverage for services that don’t have an A or B from the USPSTF. Insurance companies would be wise to not cover services that don’t provide benefit to their patients or worse, have the potential to harm them. To further scaremonger this point, Dr. Gottleib warns that the USPSTF will at some point recommend against services that people now take for granted. I too am sure this will happen but I’m not sure why it’s a bad thing. If new evidence reveals that what we’re doing is useless or harmful, wouldn’t we want to stop what we’re doing?

Lastly, Dr. Gottlieb’s solution for the ‘problem’ of the USPSTF’s structure is to open it up to political considerations. The USPSTF recommendations are respected precisely because they are perceived as being based on solid evidence and not on political considerations. The panel members are private sector experts, not political appointees or government employees. While politics may influence ultimate decisions on health insurance coverage, they have no place in a careful assessment of medical best practices.

The USPSTF is a well respected body whose recommendations form the basis of preventive care services in the United States. Casting a sinister shadow on the actions of the USPSTF may serve to further his political agenda but it has no place in the practice of good medicine.

ACA: Power to Appeal When Insurance Companies Deny Claims

Fri, 17 Feb 2012 18:05:44 -0500

One of the most disheartening things I’ve witnessed as a physician is insurance denials of needed medical services in the name of saving costs or the desire not to pay for services. Well, all of that has now changed based on the Affordable Care Act. If you purchase a health plan on or after March 23, 2010, you have the right to appeal a health insurance plan’s decision. According to HealthCare.Gov, if your plan denies payment after considering your appeal, the new health law permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. If your plan denies a claim, it’s obligated to:

-Provide the reason for the denial

-Inform you of your right to appeal

-Provide appeal information in your native language (if it's not English) if the plan begins on or after January 1, 2012

-Give you their decision within 72 hours after receiving your request when you're appealing the denial of a claim for urgent care

-Give you their decision within 30 days for denials of non-urgent care that you have not yet received

-Make a decision within 60 days for denials of services you have already received

-If, after an internal appeal the plan still denies your request for payment or services, you can ask for an independent external review. If your state has a Consumer Assistance Program, that program can help you with this request

-If the external reviewer overturns your insurer's denial, your insurer must give you the payments or services you requested in your claim

Although there are many benefits associated with the Affordable Care Act, the right to appeal a decision made by an insurer is empowering. You are no longer alone. You no longer feel helpless as I did when my insurer denied reimbursement for medical equipment that was mandated by my surgeon. I had attempted to complain to my Insurance Commissioner for assistance to no avail. Martin Luther King once said "Of all forms of inequality, injustice in healthcare is the most shocking and inhumane." The Affordable Care Act strives to bring these injustices to an end.

Removing the Pump Handle

Tue, 14 Feb 2012 11:24:12 -0500

Frederick Douglass

By Robert Hayden

When it is finally ours, this freedom, this liberty, this beautiful
and terrible thing, needful to man as air,
usable as earth; when it belongs at last to all,
when it is truly instinct, brain matter, diastole, systole,
reflex action; when it is finally won; when it is more
than the gaudy mumbo jumbo of politicians:
this man, this Douglass, this former slave, this Negro
beaten to his knees, exiled, visioning a world
where none is lonely, none hunted, alien,
this man, superb in love and logic, this man
shall be remembered. Oh, not with statues’ rhetoric,
not with legends and poems and wreaths of bronze alone,
but with the lives grown out of his life, the lives
fleshing his dream of the beautiful, needful thing.

As we celebrate black history month and the incredible contributions of African Americans to American society and the foundations of this country, it’s also important to acknowledge the persistent health disparities that still exist between African Americans and other racial groups in the US.

For example, it’s astonishing to realize that the average life expectancy of an African American man is 18 years less than an Asian woman! In addition to lower life expectancy, African Americans experience disproportionately higher rates of infant mortality, heart disease, and stroke. It’s overly simplistic to dismiss these disparities to poverty, socioeconomic differences, or differential health care access. We only have to talk to our patients and look to our communities to see the ways in which social policies, whether intentionally or not, perpetuate and exacerbate these inequities.

As Dr. Tony Iton, former director of the Alameda County Department of Public Health said, these policies have over time “taken many forms, including racially restrictive covenants on property, economic redlining in banking practices, school segregation, [unfair] housing and urban renewal policies, disinvestment in public transportation, discriminatory zoning practices, law enforcement racial profiling, [discriminatory] incarceration policies, and other deliberate governmental policies and practices.” (In Hofrichter, Richard. Tackling Health Inequities Through Public Health Practice, National Association of County and City Health Officials: 2006; p. 124)

To gain some insight into these issues, I urge you to take a moment and watch some of the clips from a recent documentary Unnatural Causes. This remarkable series demonstrates the ways in which the social and structural issues such as racism, disempowerment, wealth inequality, environment, and geography impact health outcomes. It’s also not just the social and structural environments in which we are born, grow, work, and play but the emotional and psychological environments in which we live our lives, and our conscious or subconscious reactions to them, the subterranean physiologic reactions that manifest themselves insidiously through the years through psycho-neuroimmunological pathways we are just beginning to unravel.

In watching these clips, I ask you to reflect on what in your daily experience as a health professional be it a nurse, student, or physician resonates with some of these clips. Can you see the ways in which the social and structural determinants play out in the lives of your patients and in your communities? How does stress affect your own physical and mental health and well being?

While universal health care coverage and increased access to health care through healthcare reform is part of the solution, what other interventions are important to implement? What social and policy changes are necessary for these gaping health inequities to be resolved at the hospital, the community, city, state and federal level?

If we look at the lives of our patients throughout the life course, from cradle to grave, what are the loci in which we can intervene so that we are not simply addressing the symptoms of illness in our society but going after the root causes and in the tradition of John Snow, removing the proverbial pump handle?

How much further must the struggle of Frederick Douglass, Rosa Parks, Malcolm X, Martin Luther King, Jr, and so many others continue until the “lives grown out of his life, the lives fleshing his dream of the beautiful, needful thing” can thrive?