“Medicine is a social science, and politics is nothing more than medicine on a large scale.” —Rudolf Virchow
By Jim Cochrane
You probably think heart disease or stroke is a major medical issue, and for the South Eastern San Diego Disparities Project (SESD-DP) it really is—with an extraordinary vision for what to do about it: to become the first heart and stroke death free zone in the nation. Insanely aspirational, Elizabeth, one the Project’s leaders, admitted, they dream the impossible dream. And they are serious. For this largely African American community egregious disparities are a fact of life. Around 48 percent of men and 44 percent of women are afflicted by cardiovascular disease; “decimation” is how they describe the preventable deaths. No coincidence, we all know. Given our science and our resources it shouldn’t. Zipcode matters.
The key to everything in the project is that it is anchored in people who not only know their community, but they know a lot about cardiovascular disease. Many of them know it literally in the the heart of the ones they love most.
As those we met from SESD-DP kept saying, “This is a totally over-medicated community.” So it isn‘t just a medical issue at all. At least that’s true if we take our usual, truncated, and actually morally bankrupt version of medicine, which we think of mostly it in terms of scientific expertise, high-tech treatments and medications, and the bottom line. None are unimportant, nor is it that people in health care institutions personally don’t care (far from it actually). But all should be in their place, not dominating the place. We need a view of medicine “writ large.”
The good people of SESD-DP know what means. Knowingly or not, they give strong flesh to a powerful tradition of health and medicine, one most strongly advocated in modern times by the “father of pathology,” Rudolf Virchow, who, in 1848, declared his conviction that “Medicine is a social science, and politics nothing else but medicine on a large scale.” Its highest forms are not found in the technologies and chemicals governed by the guardians of hospitals and pharmaceutical industries, in the so-called “downstream” work of health care, but in relation to persons (not just bodies), communities (not just patients), disparities (not just diseases). These, the supposedly “upstream” contributors to ill-health and disease, are usually seen as someone else’s concern.
This the SESD-DP simply does not accept. Medicine, in their experience, is social. Politics is medicine writ large. It has everything to do, one can say, with the disparities that produce highly skewed patterns of illness and disease built on long and deep patterns of exclusion or control. Deal with those and medicine in the narrower sense finds its true place. And then it is not nonsense to say that no-one should die from cardiovascular disease for it is preventable and treatable if – the vital “if” – we treat the “upstream” factors as mainstream and act accordingly.
The SESD-DP sets out to just that. It works not just in but with local community people and the strengths they do have, no puny ones given what they have to do to survive. The key? Trust. Not claimed but won, and upheld! As we heard, “People don’t care about who you know but about how you care.” And we heard, “Data is important but it’s the heartbeat that counts.” And again: “We don’t want to be just part of an experiment.” Or even more bluntly: “This community has kissed any number of frogs with titles and degrees. So when the good people turn up we close our doors. We want our partners to be accountable.”
And so the SESD-DP has developed with the community a “Data stewardship agreement“ to build trust, on the principle of “no data about us without us.” With another principle at the heart of it all: Asking permission, for that has everything to do with dignity and its respect, and nothing could be more holy ground. Medicine writ large. Non-partisan in any conceivable sense, politics by another name.