Decolonizing Healthcare: Addressing Social Stressors In Medicine
What does it mean to have a healthcare system that serves everybody? And what can physicians do to address the ways in which societal challenges impact our diagnoses?
Rupa Marya, M.D., is exploring these concepts through numerous projects aimed at researching our current medical climate and collaborating with marginalized populations to make healthcare more effective and compassionate.
Following is a transcript from Marya’s 2018 Bioneers keynote presentation, in which she discusses her research and vision for the future of medicine. Watch the full keynote video here.
I am the daughter of Punjabi immigrants who came to this country in 1973, with little money but plenty of caste privilege. We grew up with family vacations driving a VW van around the Western lands. My father would stop at the reservations. He would make us get out and listen and learn and look, and see what had happened to the original people of this land. He would talk to me about colonization, because we are also a people who had been colonized by Europeans.
I am a mother of two beautiful mixed heritage boys, and I am a farmer’s wife. I’m a physician who works in adult medicine, and who witnesses society’s ills manifest in my patients’ bodies, and a doctor who sees racism and state violence as an urgent public health issue. I’m a touring musician who has played in 29 different countries, singing in five different languages with the band Rupa and the April Fishes. To use a phrase taught to me by a Miwok elder, Wounded Knee, I am an Earth person.
What I’m going to describe for you is a system of domination in which we live, and what I believe are the direct health consequences of that system for all of us. I’ll begin with a description of how we have come to understand disease in a modern post-industrial context. In the 1850s, the germ theory was developed, which described how organisms such as bacteria and viruses made us sick. That led to the development of antibiotics and vaccines and systems to limit the spread of infectious disease.
In the 1960s, with the elucidation of DNA, we entered the molecular genetic era, where we are today. Here the gene creates a protein that can cause or protect from disease. How sick or well you were was thought to be preordained somehow by your genetics. This understanding has led to many powerful diagnostic tools and targeted therapies for specific diseases.
In 2004, with the discovery of the role of RAS gene mutation in the development of colon cancer, exactly 2,000 years after Roman physician Celsus described the cardinal signs of inflammation, we are entering the era of inflammation. Instead of a reductionist approach to understanding disease, we are seeing how many pathways lead to chronic inflammation, which in turn creates the conditions for illness.
Today we will be talking about the impact of social stressors, which have been shown to cause chronic inflammation. These diseases require more systemic approaches, not simply focusing on the individual, but rather moving our gaze to the structures of society, helping us see how the individual pursuit of health is actually futile in a system that makes health impossible.
How Colonization Affects Health
To understand the root causes of pathologies we see today, which impact all of us but affect black, brown and poor people more intensely, we have to examine the foundations of this society, which began with colonization. To me, to be colonized means to be disconnected and dis-integrated from our ancestry, from our Earth, from our indigeneity, our Earth-connected selves. We all come from Earth-connected peoples, people who once lived in deep connections with the rhythms of nature. I believe it is not a coincidence that the colonization of this land happened at the same time Europeans were burning hundreds of thousands of witches, those women who carried the traditional indigenous knowledge of the tribes of Europe.
Colonization is the way the extractive economic system of capitalism came to this land, supported by systems of supremacy and domination, which are a necessary part of keeping the wealth and power accumulated in the hands of the colonizers and ultimately their financiers.
In what we now know as the United States, this system of supremacy is expressed in many ways and with many outcomes. Today, we will focus on specific ones. First, white supremacy, which created a framework that legitimized slavery and genocide. Slavery created cheap labor, which is necessary for a functioning capitalist system. Genocide created unlimited access to resources in the form of land, animal parts, minerals, and raw materials, which are also necessary for a fully functioning capitalist economy. As capitalism functions, it further entrenches these systems of supremacy.
We all know that white supremacy is the scary guy with the swastika and the hood. But it can also look like any place where there is an abundance of white people in exclusive contexts, where power and access is not readily ceded to others.
Please remember, lest you get caught up in a tsunami of guilty feelings, that as I talk about these things, I’m talking about systems of oppression that we are actually all a part of and that we all recreate, and these systems are what need to be dismantled.
There’s white supremacy and then there’s male supremacy, also known as patriarchy, which leads to the invisibilization of women’s labor, like creating the entire human race out of our bodies. Or in this context, reproducing the entire workforce and suppressing our wages, which further supports capitalism.
Patriarchy also leads to femicide, domestic violence and child abuse, which we see across all groups. We also see human supremacy, where people feel superior to the rest of living entities, thereby subjecting living soils, seeds, animals, plants, and water to horrific treatment in the name of exploiting resources, which in turn feeds the capitalist need for ever-increasing profits.
While this wheel of domination, exploitation, generation, and sequestration of wealth continues, we experience trauma as the byproduct and common pathway. Many studies show us that chronic stress and trauma create chronic inflammation. When we look at the top ten causes of death in occupied Turtle Island, we see diseases that have been described to us as diseases of lifestyle or ones that come about because of poor choices. Maybe we eat too much fried food. Maybe we don’t exercise enough. Maybe we have a genetic predisposition. What these diseases have in common in their pathogenesis is a component of inflammation, and we are just starting to parse out how the social stressors and the very structures of society contribute to and exacerbate this chronic inflammatory state.
It is short-sighted to see these diseases as caused by individual poor choices in the context of a genetic predisposition. I see them as diseases that are virtually impossible to avoid because of the system in which we live, which generates a biological milieu of inflammation through trauma, chronic stress, environmental degradation, and damaged food systems. I see these as diseases of colonization.
If you’re a Native person, you’re like, duh. It takes science and medicine a long time to catch up with Native knowledge. This is not news to Native people. When I met Oglala Lakota elder Candace Ducheneaux in Standing Rock, she talked to me about how these diseases that are so common in modern society and more heavily so in Indian Country are diseases that were brought by the colonizers.
We talked about diabetes, which I had been taught in medical school is a disease of insulin resistance. Either your pancreas doesn’t make enough insulin or your body’s cells are not sensitive to the insulin. These are both ways of seeing things that are based in a sense of individualism and predetermination.
On the Standing Rock reservation, before the damming of Mni Sose or the Missouri River, diabetes was rare. Actually across Turtle Island, diabetes was virtually nonexistent. Once the river was dammed, it ended up flooding nearby cottonwood forests. By shifting the ecology through a colonizing force, the people became more dependent on the cash economy for their food and medicine, and they lost the essential cultural connection to their traditional ways. This tragic loss of the commons is a hallmark of capitalist society, and the impact is felt in the individual body.
After the damming of the river, rates of diabetes skyrocketed. This story is similar for tribes all over Turtle Island. It is important to recognize this didn’t happen simply because people became more sedentary and consequently more obese. This happened because of colonization, not by changing the indigenous body, but by changing the social structures around that body, which in turn creates disease.
One powerful study from Alberta demonstrated that First Nations tribes that had maintained their cultural continuity specifically through language had lower rates of diabetes. Just imagine that.
This is what is protective. It’s not the low carb, paleo diet. It’s not exercise. It’s not the latest fad or trend. This study also showed that self-determinism has a powerful protective effect from diabetes for Indigenous People. These same factors had a protective effect against suicide for Indigenous People in Canada, who experience rates two to five times the national average. This example, to me, demonstrates how disease is a complex manifestation of social and biological influences on groups of individuals that results in a common expression – here, diabetes.
While we can understand this clearly from a Native American experience, we must be aware that these social structures of domination produce trauma and inflammation for all of us. We are all affected.
So what can we do in the face of this knowledge that can seem so overwhelming? Simple things can have huge effects.
To heal the diseases that are caused by the trauma of colonization, we must decolonize. If colonization represents a dis-integration and a disconnection, we must reconnect. Our work is two-pronged: to reintegrate and to dismantle. We must reintegrate what has been divided and conquered in our societies, between our peoples, between us and the natural world around us, and within ourselves. We can do this in many ways: by promoting acts that increase local autonomy and self-determinism, by exposing the myth of treating the individual as limited in its ability to actually address root causes of diseases, by reconnecting to who we were before our respective colonization – through songs, traditional knowledge, reawakening our food and medicine ways, and reawakening our relationships to each other, to the Earth around us, and to other beings. We must dismantle those systems of domination that create and recreate cycles of trauma and inflammation, those systems that work in service of capitalism.
This is my vision of holistic healthcare.
Integrated, Holistic Healthcare
What does that look like for my work? How do I use my whitecoat privilege to address things systemically? Aside from starting to address diseases with my patients in the hospital as directly related to these phenomena, I’m doing these things:
With regards to integration, I have been invited to help create a clinic and farm to develop the practice of Decolonizing Medicine at Standing Rock, together with tribal members and healers Linda Black Elk and Luke Black Elk, great-grandson of Black Elk medicine man. We have been developing a framework for how to offer care that centralizes Lakota cosmology, an understanding of disease and health, and to create a model that can be replicable to other places and in other specific contexts.
We have incredible partners, including Mass Design Group and National Nurses United, as well as the Do No Harm Coalition at UCSF, who are over 400 healthcare workers committed to ending systems of oppression as a way of insuring health for all. We have raised over a million dollars so far, thanks to generous gifts from the Jena & Michael King Foundation, Colin Kaepernick, and crowdfunding, and seek five million more to break ground on this exciting project.
The Justice Study
With regards to dismantling systems of oppression, I have been working on a national study of the health effects of law enforcement violence or terrorism, called the Justice Study. We were asked by the community fighting for justice for 26-year-old Mario Woods, who was gunned down by SFPD in 2016, to create a study that would answer this question: If the wound is police violence and the medicine is justice, what happens to our health when the medicine is not given?
We gathered a team of public health workers and researchers, and we are currently actively compiling data. It’s already illuminating, showing how many areas of people’s lives are affected by police violence. We know that Native Americans, Black and Latinx people experience disproportionate rates of police violence, and we can see that they are most impacted by the long-standing effects of violence. How does this reality contribute to the health disparities that we see?
Across all races, we are being traumatized, with black, brown, and Indigenous people being affected more intensely. We are continuing to collect data, and we’ll be offering it to policy makers who wish to shape community safety away from models that uphold white supremacist frameworks into ones that create safety and mitigate harm for all of us.
What I want you to remember is this:
- Health is impossible when living in systems of oppression.
- We cannot effectively treat diseases like diabetes with a drug without addressing the systems that make diabetes so prevalent.
- We must redefine the scope of healthcare workers and the work of healthcare to include not only care at the bedside of the individual, but dismantling the systems of oppression that create the conditions for illness.
- And finally, we must reintegrate with the Earth, with each other, and within ourselves. We must decolonize.