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Moving the Needle on Social Justice

April 2, 2019
Photo by Robert A. Lisak
Since 2003, asylum seekers requiring a medical evaluation have been referred to the Yale Center for Asylum Medicine by attorneys from Yale Law School and the University of Connecticut Law School, as well as advocacy groups.

The marginalization of members of our society due to race, socioeconomic status, gender and sexual identity, education, or other factors is unfortunately also reflected within many aspects of our national health care system. Social inequities play out at both an individual and systemic level; social justice attempts to improve the lives of those who are disenfranchised. YSM faculty, students, and staff have made a concerted effort to address social justice issues through initiatives that range from curricular reform to research to patient care. This work extends to involving community representatives in our efforts to conduct research and improve health.

On the education front, the U.S. Health Justice (USHJ) elective, created by two medical students, Tehreem Rehman, MD ’18 and Robert Rock, MD ’18, aims to educate health professional students about social determinants of health and the obstacles to favorable health outcomes encountered by marginalized populations. Dr. Rock also created “Making the Invisible Visible: Art, Identity & Hierarchies of Power,” a session using art to explore the expression of bias in western culture and its impact on patient-provider relations. Originally developed as part of the USHJ elective, the session is now included in the required curriculum for first-year medical students.

While the curriculum currently addresses social justice through the USHJ course, the integrated LGBTQI health curriculum, clinical clerkships that address health equity, and various lectures and workshops, there remains a need to incorporate social justice more broadly into the education of our students. Accordingly, the Educational Policy and Curriculum Committee established the Subcommittee on Diversity, Inclusion and Social Justice in Medicine. This group issued a report last March that has led to the establishment of a Health Equity thread to be integrated into the four-year curriculum. It will prepare students to provide compassionate, patient-centered care that takes into account patients’ circumstances and to pose clinically relevant research questions that address health equity. A faculty leader, supported by the Office of Diversity, Equity and Inclusion and Medical Education, will oversee the development and implementation of this expanded curriculum. We have also created a new leadership structure (currently being implemented) for the Office of Student Research that will embrace and support a broader range of research interests and methodologies, including areas related to social justice.

The National Clinician Scholars Program (NCSP) is a unique interprofessional program that provides unparalleled training for physicians and doctorate-trained nurses as change agents driving policy-relevant research and partnerships to improve health and health care. NCSP fellows are committed to health equity, an understanding of the multiple complex determinants of health, optimal delivery of health care, and engaging communities at all levels, which is crucial for improving health. Yale was one of the founding institutions of NCSP, which now includes six sites.

Another reflection of our commitment to social justice is the Committee for Diversity, Inclusion, and Social Justice (CDISJ), formed in 2016. Comprised of faculty, students, and members of the administration, its charges include advancing social justice—which is strongly tied to diversity and inclusion—within the school and the wider community. Its commitment to and efforts in this area—largely driven by students—has been critical to many of the improvements in our social justice programs.

Our students are very passionate about social justice and have spearheaded such initiatives as standardized questions during medical school interviews that take into account an expanded definition of excellence, as well as programming aimed at diversity and social justice during interviews and Second Look. In an effort to understand the needs of those who are marginalized, students consulted with members of the community and community-based organizations about services they utilize when selecting organizations to receive donations from the latest Hunger & Homelessness Auction held in December.

Moving forward with our social justice work requires partnering with the community in a bidirectional dialogue that involves listening and taking into account members’ priorities and needs. In 2011, the Yale Center for Clinical Investigation (YCCI), established the Cultural Ambassadors program, led by YCCI deputy director Tesheia Johnson, MBA, MHS, in which Yale researchers partner with community and faith-based organizations to increase representation of people of color in clinical research. In this robust program, community representatives receive extensive training and regularly meet with investigators, providing input on study design and subject recruitment and bringing back what they learned to their constituents. YCCI recently expanded this initiative— which has become a national model—by collaborating with Duke University to implement the program in North Carolina. Both institutions are recipients of the National Institutes of Health Clinical and Translational Science Award (CTSA), which is designed to accelerate the translation of scientific discoveries into practice to improve health. YCCI is also partnering with the FDA to encourage underrepresented minorities to take part in clinical research and pursue careers in the health professions. The partnership is focused on raising awareness about the need for minority populations to participate in clinical trials, patient-centered approaches to care and research, and the role technology plays in achieving these goals.

For more than 15 years, physicians at the Yale Center for Asylum Medicine, led by Katherine McKenzie, MD, have performed medical evaluations on asylum seekers who have experienced persecution and torture in countries around the world on account of race, religion, ethnicity, political opinion, or membership in a particular social group. Their findings are presented to immigration authorities. Medical students, residents, and fellows at Yale participate in these evaluations and can complete formal training with advocacy groups that partner with the center.

There are scores of investigators at the school conducting research on health equity, social determinants of health, barriers encountered by underrepresented minorities in health professions, and other areas that are connected to social justice. Although there are too many to recount here, a few of these programs are highlighted below:

  • The Center for American Indian Research and Treatment, led by Christopher Cutter, PhD, who works with Mark Beitel, PhD, leverages existing expertise and resources in Native American Tribes to identify solutions to pressing mental health issues. For example, the center is collaborating with the Peoria Tribe of Indians of Oklahoma to develop an approach to opioid overdose prevention that includes health counseling by nurses and peer support recovery counselors.
  • The Division of Prevention and Community Research in the Department of Psychiatry, led by Jacob Tebes, PhD, conducts studies to enhance the prevention of psychiatric and substance use disorders and the promotion of resilience. This work, frequently carried out in community settings that involve traumatized, at risk, or clinical populations, aims to integrate cultural approaches into practice, research, and policy.
  • The Equity Research and Innovation Center (ERIC), led by Marcella Nunez Smith, MD, MHS, generates actionable research that promotes population health and health care equality. ERIC projects include developing a tool to assess patient-reported experiences of discrimination in health care and establishing the Eastern Caribbean Health Outcomes Research Network that encompasses 35 organizations and is helping to address disease disparities for millions of adults in the Eastern Caribbean, New York, and New Jersey.
  • The Health Justice Lab, led by Emily Wang, MD, includes the Transitions Clinic Network, a growing consortium of more than 50 community health centers nationwide that employs individuals with a history of incarceration as community health workers to care for those recently released from correctional facilities.
  • The Yale Program in Addiction Medicine, led by David Fiellin, MD, and Jeanette Tetrault, MD, encompasses treatment programs in the inpatient, Emergency Department, and outpatient settings; an Addiction Medicine Fellowship; career development and training programs for providers; and an inpatient Addiction Medicine Consultation Service. Research led by Gail D’Onofrio on emergency department-initiated buprenorphine treatment has led to the adoption of this novel and effective strategy into practice around the country. Our commitment to combating substance use disorder includes a wealth of research on treatment interventions and an addiction thread that will be embedded in our medical school curriculum.

We have made significant strides in the arena of social justice, but there is much to be done as we examine and change the structures that create health care inequities. We will continue on this path as we contribute to creating a societal shift in which education and health care are equitable for all.