The Hidden Voices of Medicine: Championing Health Equity through Social Determinants

   The history of medicine is inextricably intertwined with various ethical, socioeconomic, and cultural perspectives; it should not be confined to a singular perspective, but rather include several perspectives that can help mitigate misinterpretations and prevent false assumptions [1].  However, despite medicine impacting all human lives, the complete acknowledgment of traditionally marginalized medical pioneers remains an unrealized imperative. At the Emory University School of Medicine, a group of advocate students began addressing this disparity by renaming the four societies which students are divided into for participation in small-group learning environments. This initiative works towards highlighting the hidden voices that have shaped our modern medical education, training, and future careers. The four individuals who are the new society namesake embody our school’s history of excellence in the service of our community. 

The societies were renamed after: Dr. Luella Klein, the first woman to serve as chair of an Emory department and the first woman to serve as president of the American Congress of Obstetricians and Gynecologists; Dr. Rebecca Crumpler, the first female African American physician in the United States; Dr. Hamilton Holmes, the first African American to graduate from the Emory University School of Medicine in 1967 and served as Associate Dean in the SOM and Chair of the Orthopedic Surgery unit at Grady; and finally my society which was renamed after Dr. Helen Rodríguez Trías, a public health expert and a women's rights activist who served as the first Latina director of the American Public Health Association.

Despite being Puerto Rican and a future physician, I had never heard of Dr. Rodríguez Trías throughout my medical training. Once I began learning about her accomplishments and professional career I was surprised to learn how, similar to the other namesakes, her achievements have impacted the lives of many yet her story remained largely untold. Therefore, I decided to begin amplifying her life’s story as she serves as an excellent role model and inspiration for future and current physicians. During the inaugural Rodríguez Trías Society Pinning Ceremony, I spoke to my classmates about who Dr. Rodríguez Trías was and encouraged them to use her life’s story as a source of inspiration for our careers.

Dr. Rodríguez Trías is a physician of Puerto Rican origin, who faced various setbacks throughout her life yet remained persistent in her selfless goal of providing equitable healthcare for all. While studying in New York, her intelligence was questioned despite her good grades and English proficiency. As a college student, she had to place her education on hold due to financial constraints. Still, it was her unwavering commitment to learning, social justice, and healthcare equity that truly set her apart. As a pediatrician and obstetrician-gynecologist, she dedicated her career to improving the health outcomes of the most vulnerable among marginalized communities, particularly women and children. As a fellow obstetrician-gynecologist, Dr. Klein also championed health care equity, particularly for adolescent, low-income, incarcerated, LBTQI+ women; women of color; women with disabilities; women with HIV; and other underserved populations. Dr. Klein brought these issues to the national level by overseeing the American Congress of Obstetricians and Gynecologists’ infant mortality review, substance abuse treatment initiative, and domestic violence intervention program [2].

Serving the Most Vulnerable in Our Community
During her medical education at the University of Puerto Rico School of Medicine, Dr. Rodríguez Trías was inspired by one of her professors, Dr. Jose Sifontes. During the 1950s in Puerto Rico, he was a pioneer in pediatric tuberculosis as he emphasized the social determinants of health; marking tuberculosis as a disease of poverty, malnutrition, and overcrowding. His sense of what was going on in his community is what propelled Dr. Rodríguez Trías to begin her advocacy for health justice. While completing her residency at the University Hospital in San Juan, Dr. Rodríguez Trías went on to establish Puerto Rico's first center for neonatal care. Within the first three years of its inauguration, the hospital witnessed a fifty percent reduction in newborn mortality rates [3].

 

 

 

 

 

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Figures 1 and 2: Dr. Rodríguez Trías caring for pediatric patients in Puerto Rico [3].

    A physician who faced innumerable barriers yet spent her medical work providing care for those who traditionally lacked access was Dr. Crumpler. She spent part of her career in post-Civil War Richmond, Virginia. She described her experience there as “a proper field for real missionary work”. A large population of newly emancipated African Americans, due to poverty and racism, would have otherwise received no medical care if not for her presence. Despite her facing sexism and racism by her colleagues, Dr. Crumpler was devoted to her mission of helping those in need [4].

 

 
Addressing the Social Determinants of Health
Dr. Rodríguez Trías's medical education and training are an excellent example of how the social determinants of health have become a pivotal integration of how modern medicine is taught and practiced. Emphasizing a holistic view of medicine has become such an integral part of medical education and training that the Accreditation Commission on Colleges of Medicine requires medical schools to incorporate the social determinants of health into their curriculums [5]. The Emory University School of Medicine integrates this learning pillar beyond the classroom walls with the longitudinal Community Learning and Social Medicine Curriculum (CLSM) which all students partake in beginning of their first year. As a medical school that attracts a diverse pool of applicants, the preclinical students collaborate with community partners of the metro Atlanta area to better understand systemic challenges that affect community members’ healthcare choices and ultimate health outcomes. Similarly, to Dr. Helen Rodríguez Trías's work, CLSM was born out of advocacy [6].

Furthermore, Dr. Rodríguez Trías was a trailblazer in addressing the intersectionality of health disparities. She understood that health outcomes are influenced by a multitude of factors, and promoted our current understanding and practice of cultural humility. Her groundbreaking work in recognizing and addressing these disparities challenges medical students to approach healthcare with a holistic perspective, acknowledging the diverse and interconnected aspects of patients' lives to their health. Through CLSM, Emory broadens students’ cultural humility towards our patients and refines our own unconscious biases when practicing history-taking, presentations, development, and execution of patient care plans [6].

Political Activism in Medicine
In addition to her commitment to addressing the social determinants of health, Dr. Rodríguez Trías’s academic relationships extended into the field of social and political activism. Throughout her time at the University of Puerto Rico in San Juan, she fought for the injustices of Puerto Rico’s colonization, and during her time in New York, her involvement with Barnard College sparked her fight for women’s and reproductive rights [7]. She understood that political activism does not mean discussing politics with patients, but rather it is a privilege physicians earn to advance the medical practice at a larger scale [8]. Her advocacy as a physician was one of many to influence the Doe v. Bolton Supreme Court case which overturned the anti-abortion law of Georgia in 1973 and was decided on alongside Roe v. Wade [9].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figures 3 and 4: Dr. Rodríguez Trías participating as an advocate in rallies [3].

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Dr. Rodríguez Trías’s political activism continued as she was also a pivotal figure in dismantling the United States’ eugenic sterilization campaigns against marginalized women. After the 1927 Buck v. Bell Supreme Court decision, involuntary sterilization became a more common and legally funded practice [10]. Throughout the mid-20th century, this campaign reached the highest rate of sterilization in the world in Puerto Rico, with approximately one-third of Puerto Rican women being sterilized [11]. In 1937, during the Great Depression, when operating the Milledgeville State Hospital was becoming a great cost, Georgia passed its eugenic sterilization law. This law permitted the involuntary sterilization of over three thousand women in the state. The majority of these sterilizations were completed under the guise of Dr. Thomas G. Peacock, who was both the head of the State Board of Eugenics and the superintendent of the asylum in Milledgeville [10]. During the rights revolution of the 1960s and 1970s, Dr. Rodríguez Trías drafted federal guidelines that required a woman's written consent to sterilization in a language they could understand and set a waiting period between the consent and the sterilization procedure [11]. What was once the world’s largest psychiatric institution, holding up to 13,000 patients in over 200 buildings, has now become a primarily abandoned and repurposed site [12].

 

 

 

 

 

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Figures 5 and 6: Milledgeville State Hospital, now known as Central State Hospital [13].

 

An individual who placed activism and social justice at the forefront of his work was Dr. Holmes. Inspired by his grandfather who was a physician, Dr. Holmes was determined from an early age to become a doctor. He graduated from Atlanta’s elite Henry McNeal Turner High School in 1959 as senior class president, class valedictorian, and co-captain of the school’s football team. He was determined to attend the University of Georgia as their science offerings were superior to other schools. He was finally successful in 1961 alongside Charlayne Hunter-Gault, becoming the first to desegregate the University of Georgia. The constant degradation and threats of violence by his classmates did not stop him from being a focused and outstanding student. Later in his career, he would join the board of trustees of the University of Georgia where he established a scholarship for future Black students [14].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 7: Dr. Holmes and Mrs. Hunter-Gault at their inaugural namesake lecture at the University of Georgia [14].

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Drawing Inspiration for the Future
I hope that all medical students draw inspiration from the new namesakes' courage to confront systemic injustices. Their fearless commitment to speaking out against discrimination and inequity serves as a powerful reminder that being a healthcare professional is not only about treating illnesses but also about addressing the root causes of health disparities. Their life’s work serves as a call to action to engage in leadership roles, influence policy changes, and actively contribute to shaping the future of healthcare. These all serve as examples of how the role of physicians extends beyond the exam rooms and hospital beds. Their life and legacy provide a roadmap for medical students aspiring to make a meaningful impact in the world of healthcare and for future generations. 

Dr. Rodríguez Trías leaves a legacy that can be remembered using her own words “We cannot achieve a healthier us without achieving a healthier, more equitable health care system, and ultimately, a more equitable society.”

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 8: Helen Rodriguez-Trias, M.D.[3].

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I want to express my gratitude to the various Emory medical students who for years advocated and fought for the renaming of the Emory University School of Medicine’s Societies. Their work has highlighted some of the many hidden voices that have shaped our current practice of modern medicine and serve as an inspiration for future physicians like myself. 

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References
[1] Bârsu, Cristian. “History of Medicine between Tradition and Modernity.” Medicine and Pharmacy Reports, vol. 90, no. 2, 26 Apr. 2017, pp. 243–245, https://doi.org/10.15386/cjmed-794.

[2] “The Legacy of Emory at Grady: Luella Klein.” Emory Daily Pulse, 27 August 2015, https://www.emorydailypulse.com/2015/08/27/legacy-emory-grady-luella-klein-md/. Accessed 14 July 2024.

[3] “Changing the Face of Medicine | HelenRodriguez-Trias.” Nih.gov, 3 June 2015, cfmedicine.nlm.nih.gov/physicians/biography_273.html.

[4] Rothberg, Emma, and Ruth Bader Ginsburg. “Rebecca Lee Crumpler.” National Women's History Museum, 1 October 2021, https://www.womenshistory.org/education-resources/biographies/rebecca-lee-crumpler. Accessed 14 July 2024.

[5] Henderson, Ron. “Accredited Medical Schools, International Medical School Accreditation.” ACCM, accredmed.org/standards/#STANDARD_5_CURRICULAR_CONTENT. Accessed 3 May 2024.

[6] “Longitudinal Community Learning and Social Medicine Curriculum (CLSM) | Emory School of Medicine.” Med.emory.edu, med.emory.edu/clinical-experience/community-learning/uhi/education/clsm/index.html. Accessed 3 May 2024.

[7] Wilcox, Joyce. The Face of Women’s Health: Helen Rodriguez-Trias. American Journal of Public Health, Apr. 2002. Accessed 3 May 2024.

[8] Fuller JM. Making Grassroots and Political Activism a Part of Medical Practice. JAMA. 1998;279(21):1696B. doi:10.1001/jama.279.21.1696

[9] Reproductive Laws for the 1990s. edited by Sherrill Cohen and Nadine Taub, Clifton, New Jersey, Humana Press, pp. 353–358. Accessed 8 May 2024.

[10] Smith, Stephen. Eugenic Sterilization in 20Th Century Georgia: From Progressive Utilitarianism to Individual Rights. Dec. 2010.

[11] “The Dark History of Forced Sterilization of Latina Women | Panoramas.” Web.archive.org, 15 Apr. 2019, web.archive.org/web/20190415061918/www.panoramas.pitt.edu/health-and-society/dark-history-forced-sterilization-latina-women. Accessed 8 May 2024.

[12] Monroe, Doug. “Asylum: Inside Central State Hospital, Once the World’s Largest Mental Institution.” Atlanta Magazine, 18 Feb. 2015, www.atlantamagazine.com/great-reads/asylum-inside-central-state-hospital-worlds-largest-mental-institution/.

[13] “Eugenics in Georgia.” New Georgia Encyclopedia, www.georgiaencyclopedia.org/articles/government-politics/eugenics-in-georgia/.

[14] Fikes, Robert. “Hamilton Earl Holmes (1941-1995) •.” Blackpast, 8 December 2021, https://www.blackpast.org/african-american-history/people-african-american-history/hamilton-earl-holmes-1941-1995/. Accessed 14 July 2024.

[15] Nash, Amanda. “Hamilton Holmes.” New Georgia Encyclopedia, 19 August 2005, https://www.georgiaencyclopedia.org/articles/history-archaeology/hamilton-holmes-1941-1995/. Accessed 14 July 2024.