Treating the types of conditions and injuries which present in this era requires doctors to become advocates as well as healers, writes Dr Jin Russell.

Last Thursday, the National Rifle Association (NRA) posted a deeply provocative and surprisingly idiotic tweet about doctors in the United States.

This move was a retaliation against an email from the Annals of Internal Medicine, a high impact medical journal issued by the American College of Physicians (ACP), highlighting firearm-related research and the release of the ACP’s most recent position paper on firearms. The NRA article accompanying the tweet accused the medical profession of “respecting their own rights and opinions far more than they do those of law-abiding gun owners” and, shockingly, of publication bias in favour of gun-control.

There’s a saying about letting sleeping dogs lie. Better yet, there’s the Hogwart’s motto from Harry Potter – ”Draco Dormiens Nunquam Titillandus“, or, “Never tickle a sleeping dragon“. The NRA would’ve been better to have left the Medical Dragon alone.

Physicians were furious. Over the next 72 hours they flooded Twitter with posts expressing their outrage, creating the hashtag #ItIsOurLane.

Esther Choo, emergency physician and associate professor at Oregon Health & Science University, retorted “We are not anti-gun: we are anti-bullet holes in our patients.”

Others, such as Mary Brandt, a paediatric surgeon in Houston, posted multiple links to scientific papers on gun regulation.

But some of the most effective and hair-raising tweets came from a large number of physicians who testified to the carnage wreaked by guns that they had personally witnessed. The stories of their patients. Horrific photos of blood-soaked gauze, the aftermath of trauma surgery on gunshot victims. It makes for grim reading.

Even the American College of Physicians and the American Academy of Paediatrics used their official twitter feeds to publicly commit to advocacy on the issue.  Closer to home, Australian physicians have made headlines while advocating for the removal of children and their families from the offshore detention centre, Nauru. In 2015, over 1000 doctors, nurses and clinical support staff from the Royal Children’s Hospital in Melbourne protested against the Australian Government’s policy of keeping children in detention. Physicians were at the forefront of bringing eyewitness testimony to the attention of the public.

The hospital’s head of general medicine, Dr Tom Connell, speaking to the media, described the effects of detention on children’s wellbeing: “Our team see children with nightmares, bedwetting, and severe behaviour problems… anxiety and depression. It’s become so common that it’s almost normal in children from detention to have these symptoms.”

Dr David Isaacs, a paediatrician at Westmead Hospital who has treated refugee children both on Nauru and on Australian soil, has been a vocal critic of Nauru detention policy. He shared harrowing stories of children he treated on the island detention centre. “I saw a six-year-old child who tried to hang herself with a fence tie. I saw a 15-year-old brave lad who’d sewed his lips up and his parents were cross with him for doing it, and he was cross with them because when he collapsed they let the medical staff cut the ties on his lips,” he recalled to the media in 2015.

In September of this year, the president of the Australian Medical Association, Dr Tony Bartone, wrote directly to the Australian Prime Minister Scott Morrison on behalf of its membership urging a change in detention policy. The plea was rejected. Then just last month almost 6,000 Australian doctors, as well as 16 medical professional bodies, signed an open letter calling for the transfer of refugee children and their families off Nauru as part of the #KidsOffNauru campaign initiated by World Vision Australia and backed by over 300 organisations. Shortly afterwards on the 31st October, the Australian Government committed to relocating all the children on Nauru to Australia by the end of the year.

The nature of medical work is increasingly technical and hurried. This leaves little time for physicians to advocate to challenge the structural determinants of poor health – those ‘wicked’ injustices that arise from the way in which our society is organised, rather than from a bacterial toxin, a rampant virus, a genetic quirk. But the medical profession is, as the Hogwart’s motto imagines, a sleeping dragon. When provoked, its reaction is a pretty mighty spectacle to behold. It roars with harrowing stories, with compelling data, and with images of bloodied theatre floors. It upholds a professional ethic that binds doctors to being completely for the other. If we see violence, we must testify to that violence.

Doctors are ideally positioned to advocate. Aristotle described various elements of persuasion: ethos – the credibility of the presenter; pathos – the ability to appeal to emotions; and logos – the ability to appeal to the logical mind, sometimes with facts and figures.

Doctors can use all three. We have the privilege of hearing people’s stories first-hand, we are eye-witnesses to their suffering. We are trained to interpret data and to contribute to scientific research. Since the Hippocratic Oath, doctors have pledged to live according to a shared ethic of care and concern for others rather than self. We treat and heal wounds as we are able; we will treat anyone who needs help.

To these, add organisation. And this is the real dynamite. We often lament the extent to which we are externally regulated, but the fact is that our medical societies and professional bodies result in highly organised communities of doctors, sharing new knowledge and fostering empathy and action towards shared concerns. Our membership fees fund staff positions for policy and advocacy committees housed within these organisations for which doctors can volunteer their time. Advocacy campaigns can zip through medical networks like (and forgive me for the cheesy medical metaphor, please just go with it) an action potential along a nerve cell axon. Like a bundle of purkinje fibres. We are not left advocating as individuals. We can advocate through highly organised medical institutions.

This ‘quartet of medical advocacy’ – ethics, scientific evidence, stories and images, and organisation – means that when doctors do speak up on issues, we can be highly effective advocates.

The surgeon who sews up the gunshot victim is at their best. The physician gently asking after the psychological wellbeing of a refugee child is at their best. But we are all at our best when we are advocating for our patients, with one voice.

The surprising thing I have learnt about medical advocacy, however, is that it is therapeutic for doctors themselves. Doing medicine within our speciality silos, living in medical ‘tribes’ – the day-to-day life of a medic can sometimes feel as if we are at war with one another, battling over a deluge of patient referrals and vexing clinical decisions. However, we can all agree that it is wrong to keep children in detention and deny them medical treatment. Just as we advocated for seatbelts to prevent injuries from motor accidents, and for pool fences to prevent child drownings, we can advocate for safer regulation around who can purchase guns, what guns can be purchased, and how those guns can be stored. Advocacy can unite the medical profession in a way that our day-to-day work is often unable to.

This should in no way suggest that doctors are the only health professionals who are positioned to effectively advocate for their patients. Nurses, midwives, and other health professionals have taught doctors a thing or two about advocacy on more than one occasion. Indeed, nurse and midwifery organisations are powerful partners of the #KidsOffNauru campaign for instance.

Here in Aotearoa there are issues that require urgent health advocacy. Harms that are done to our patients that we witness first-hand. The wounds of poverty, of food insecurity. The devastation of homelessness. The scars of domestic violence. The terrible sound of an infant battling whooping cough. To name but a few.

“Advocacy is about speaking up for people with no voice,” Dr David Isaacs stated when reflecting on why he advocates. “I have not been a good enough advocate before and I’ve decided it was time I was.”

To combat some of the largest drivers of ill health in this new century, we need doctors to be advocates, not just healers.

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