Social Change and Medicine: Band-aids or Levers?

Of the many paths into social change work, medicine doesn’t always seem like an obvious one. And though I’ve decided that this is the path I want to take, I’m still often unsure about whether this is the most effective way to do work that is aimed at addressing social inequalities and injustices. That uncertainty has been particularly heightened in the past couple of weeks as I’ve been visiting and interviewing at medical schools (not the best situation in which to suddenly start doubting your decision to pursue a medical career, I will readily admit, but at least I know those interviewers are doing their job effectively). At more than one interview at this point I’ve been confronted with the question of why I need to pursue a career as a physician if my focus is on issues that operate at the level of social structures and policy. These comments are often followed up with the suggestion that a career in public health seems more suitable, and would require significantly less of a time and financial commitment. I’ve developed responses to these questions that mostly seem to satisfy my interviewers, but have also left some (unvoiced) doubts in my own mind about the effectiveness of the work I’ve chosen.
To be clear, there is no doubt in my mind that those who practice medical and heath-related work need to be mindful of social inequalities and disparities. There are huge bodies of evidence showing that health disparities exist across lines of race, gender, class, and other social categories, as well as evidence showing that health-related outcomes can be interpreted as the downstream effects of a wide array of social inequalities. This is essentially what the field of ‘social medicine’ is all about, and what people mean when they talk about the ‘social determinants of heath’: that there are upstream factors that often operate at the social or population level (e.g. education, income disparities, natural and built environment) that can have tremendously influential impacts on a person or community’s health. Given the importance of these determinants, providing clinical care for individuals and communities without being mindful of these factors and the way that they differentially affect the health of different people is, to my mind, incomplete care.
I have been an avid consumer of the social medicine Kool-Aid, having taken long gulps of it through the past few years. I need no further convincing that an awareness of social inequalities can improve the way that we practice medicine. What I am less sure about is whether it also works in the other direction. Does practicing medicine, providing individual-level or community-level clinical care, do anything towards actually correcting social inequalities and disparities? To put it more concretely, does improving the health of communities of colour do anything towards ending racism? To some degree, I think the answer is yes, in that improving health works against the effects of racism and sexism and other kinds of oppression, and also building physically and emotionally healthy communities allows other important work to take place. Still, I can’t help but feel that affecting health itself is so far downstream as to be ultimately insignificant, and that any change needs to happen somewhere much higher up in the chain.
As you might be able to tell, my thoughts in this area are pretty muddled. And certainly, my desire to pursue medicine isn’t based solely on my goal to do social change work: my other academic, professional and personal interests (as well as a healthy interest in medical dramas) have all pointed my down this road. Still, I’ve come to the decision in the last few years that I want to contribute as much as possible to anti-oppression struggles, and it’s sometimes hard for me to align that goal with other priorities. My own pre-professional angst aside, it’s still an unanswered question for me whether acting at the level of downstream outcomes like medicine does is an appropriate way of creating social change, and whether work at the level of individual care can be used to effect change at the scale of social structures and institutions.

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