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The importance of social medicine

By George Thomas

Binayak Sen, who was arrested in Chhattisgarh in May, is one of very few medical practitioners in India who see their role as not just saving individual lives but examining and highlighting the social context of disease. Is it just to arrest a doctor who is acting according to his conscience?

The arrest of Dr Binayak Sen, a paediatrician in Chhattisgarh in May 2007, focuses attention on the role of a doctor in a democracy in general and in India in particular.

The general perception of both the general public and the medical fraternity is that the function of a medical practitioner is to cure, or aid in the cure of, illness. If the idea of prevention comes in at all, it is in the form of interventions like vaccination and public sanitation. All doctors are taught, at least in classes on social and preventive medicine, that infectious diseases are the major cause of mortality in India, and that these diseases thrive in conditions of undernutrition which is endemic in India.

But social and preventive medicine is the orphan of medical education, and most doctors see themselves as saving individual lives - the stuff of reality television. Therefore a doctor like Binayak Sen, who chooses to look at the social context of disease, is considered a maverick. There is really nothing new about considering the social context of disease. Rudolf Virchow emphasised it, and William Osler, the oft-quoted physician, is reputed to have said that it was not sufficient to know the disease the patient had, but equally important to know the patient the disease had.

Independent India has paid lip service to the concept of universal medical and health care, starting with the recommendations of the Bhore Committee. The fact however is that although a lot has been achieved, it is nowhere near what could have been done. India has the largest number of people with tuberculosis, preventable blindness, and many other diseases. We fare poorly in the indices of maternal, perinatal and child mortality.

Lacking a social and political perspective, very few doctors question why the health situation in India is so bad. When Amartya Sen mentions the subject it might, at best, become a topic of discussion for a few days. By and large health professionals see nothing wrong in a situation where those who can afford it can obtain the best medical care, while those who have no money may not receive even the most elementary life-saving intervention.

In India, health activism goes far beyond anti-tobacco campaigns. It recognises that poverty and injustice are the major sources of ill health. Therefore activists like Dr Binayak Sen involve themselves in campaigns to improve the economic and social condition of the people among whom they work. This can be considered preventive medicine in the purest sense since it seeks to address directly the most fundamental cause of ill health. Thus it is not surprising to find health activists (very few of whom are doctors), taking up issues such as environmental degradation and deprivation and discrimination, whether based on gender, caste or uneven distribution of resources, and questioning the responsibilities of governments on these subjects. Surely such activity is legitimate in a democracy?

Health activism of this kind is understood as working with people to assert their legitimate rights so that their health is safeguarded. During such activity, activists may come into conflict with the existing government. But dissent is an essential part of democracy, and it is by negotiation with conflicting ideas that a healthy democratic society develops.

The fundamental question is: Is it ethical for a doctor who is aware of the real causes of disease to refuse to get involved in trying to change those conditions? And is it just to arrest the doctor who is acting according to his conscience?

From available reports, the charge against Dr Binayak Sen is that he was in contact with a banned organisation. He was arrested under a special law which abrogates the rights of the arrested to most safeguards available to citizens of India. These safeguards are meant to prevent the arbitrary arrest of people just because the government does not like them. We must remember that for an ordinary citizen, who is not protected by being a member of a powerful political party, arrest on petty grounds is still a daily possibility. The special law takes away the safeguards of compulsory bail, and Dr Sen is still in jail without clear reason. If Dr Binayak Sen has contravened any law let him be charged. If not, he must be released immediately.

(George Thomas is an orthopaedic surgeon based in Chennai and editor of the Indian Journal of Medical Ethics)

InfoChange News & Features, June 2007