Perspective
Reflections from the National Mall
A visit to the Washington, D.C., monuments is a reminder that there’s more to health than medicine.
By Edward P. Ehlinger, M.D., M.S.P.H.
Having a couple of hours before the start of a meeting that brought me to Washington, D.C., I decided to walk to the National Mall. Even though I had been there multiple times in the past, I felt particularly compelled to revisit the memorials on the west end. That urge was fueled by the frequent references to Abraham Lincoln and Franklin Delano Roosevelt during the 2008 presidential campaign, which had ended a couple of weeks earlier. I felt a need to compare the problem-solving approaches proposed by the candidates to the actions of past leaders who had shepherded this country through similarly turbulent times.
As I approached the mall from the north, I noticed a number of middle-school children climbing on a statue tucked into a grove of trees in front of an unobtrusive-but-classic Washington-style building. Having never noticed the statue or the building before and intrigued by the energy of the crowd, I crossed the street to get a closer look. Nearing the sculpture, I recognized the image as that of Albert Einstein delightfully portrayed in bronze by Robert Berks. On a nearby sign, it was noted that the sculpture commemorated “a scientist whose work led to a new understanding of the world and who believed his work was ‘a solemn trust to be used for the common good.’”
When I asked one of the students what they were doing, she told me their science teacher brought them there “because she thinks people are going to make a big deal about science in the next few years and she wants us to get ready for the change.” “Change,” a word that had been used so often during the campaign, seemed to be unfolding right in front of me as the anti-science stance of the last eight years was already giving way to the exuberance of the next generation of scientists.
Given the impulse that had initially directed me toward the mall, I couldn’t help but notice one of Einstein’s quotations engraved on the sculpture: “As long as I have any choice in the matter, I shall live only in a country where civil liberty, tolerance, and equality of all citizens before the law prevail.” This seemed to underscore the themes of the election and rekindled my desire to gain some perspective on these issues. It was then that I noticed a sign pointing to the entrance of the National Academies of Science building.
Upon entering the building, signs immediately reminded me that the Institute of Medicine (IOM) is part of the National Academies of Science. I started thinking about the connection between Einstein and the IOM. Given the goal of both, to have their efforts “used for the common good,” I couldn’t think of a better iconic link between science and medicine than Einstein.
With that in mind, I began to think about another quote on the Einstein memorial: “The right to search for truth implies also a duty: one must not conceal any part of what one has recognized to be true.” In the context of the presidential campaign, where a lot of attention was focused on health care cost containment and insurance reform, no one seemed to recognize one of the known truths—the importance of social factors in determining health status. Although there was a lot of talk about the economy, education, war, housing, and disparities, these factors were seldom considered in discussions about health care reform.
As I stood in the atrium of the IOM, it struck me that although the IOM has made the case for addressing the social determinants of health for years, the “truth” seems to have been routinely ignored by health care administrators and policy makers. I recalled the 2002 IOM report, “The Future of the Public’s Health in the 21st Century,” which stated “that the health of populations and individuals is shaped by a wide range of factors in the social, economic, natural, built, and political environments. ... Approaching health from such a broad perspective takes into account the potential effects of social connectedness, economic inequality, social norms, and public policies on health-related
behaviors and on health status.”
The report also noted that “health care services and biomedical technologies can generally only address the immediate causes of disease … and do so on an individual basis. Preventive approaches [like policies on education, housing, a living wage, or clean air] that focus on populations are likely to have broader impact.” This was a powerful statement from an organization with “medicine” in its title.
As I stood there, the IOM’s Committee on the State of the USA Health Indicators was drafting a report that reinforces the IOM’s earlier work on the importance of the social determinants of health. The report states: “Social and physical determinants play a particularly important role in health in that they impact health outcomes directly as well as indirectly by influencing the other determinants. Social and physical determinants include SES [socioeconomic status], race/ethnicity, social support, health literacy, and limited English proficiency, and the social and physical environment in which people live, learn, work, and play.”
Noting that socioeconomic status is one of the most important determinants of health, this report goes on to highlight numerous other determinants such as access to healthful food and a healthful environment, having health insurance, education, employment, stress, housing, and transportation, along with various forms of inequity.
In reflecting on these things, I began to wonder whether the IOM has been faithful to Einstein’s admonition about truth. The IOM has certainly pointed out the truth about the importance of social determinants and the limitations of medical care; but has it been as forceful in pointing out the truth about the priorities of our health care system, which continues to direct massive resources toward the medical care of individuals while showing indifference to the known social determinants? Has the IOM taken advantage of its rights but shirked its ultimate duty to the common good?
While pondering these questions, I came across a display that noted Abraham Lincoln created the National Academies of Science in 1863. That reminded me of my initial reason for visiting the Tidal Basin monuments. I hurried out the door and across Constitution Avenue, past the Vietnam Memorial (where I stopped to find the names of my grade school and high school buddies who were among the 2 million who lost their lives in that war), up the steps and through the atrium of the Lincoln Memorial (where I was reminded of the conflicting values of the people of Lincoln’s time and the 700,000 people who died in the Civil War in order to free 4 million slaves), by the World War II Memorial (where I silently prayed for the 70 million people worldwide who perished in that conflict), and to the FDR Memorial (where I finally made the connection as to why today’s political leaders were looking to the past for guidance on addressing contemporary problems).
It was in the four rooms of the FDR Memorial, where I saw the images of the vacant faces of people devastated by the Great Depression and could feel the desperation and fear that gripped the entire nation during that time. It was in the memorial’s South Dakota granite where I read the chiseled words describing the overwhelming effects of war on individuals, families, and society. It was among the site’s four waterfalls, where I heard the cries of people yearning for leadership to help create a better future and voices expressing a willingness to work hard to make it happen. It was here that it became obvious that social, political, economic, and physical environments play a huge role in the health of people and that the economy, housing, unemployment, war, education, the environment, and public policies must be dealt with as part of health care reform.
When I reached the end, I took time to reflect on the final quotation: “The structure of world peace cannot be the work of one man or one party or one nation. It must be a peace which rests on the cooperative effort of the whole world.” It was then that I realized that while this was a memorial to FDR, it was also a memorial to the cooperative effort of all people who want a better world. I took it as a personal challenge to re-examine my role in addressing the issues that face our society.
With my meeting fast approaching, I headed back to the conference hotel. As I walked, I realized that all of these memorials on the Tidal Basin in some way related to health; but not one focused on our health care system. Perhaps the designers of the National Mall knew long before Foegel’s and McGinnis’s 1993 JAMA article that outlined the actual causes of death in the United States, that medical care contributes only about 10% to our overall health and that we should focus most of our attention on the other 90%. Without negating the importance of medical care, the monuments highlight the fact that it’s the social conditions and the behaviors that they foster that have the greatest influence on the health and well-being of people.
As I walked up 23rd Street NW past the Einstein sculpture and through Foggy Bottom toward my hotel, I passed George Washington University Hospital—a high-tech, 21st century health care facility. A couple of ambulances were arriving and people in scrubs and white coats were streaming in and out as the shift changed. In the midst of all the commotion, a homeless man sat quietly in a dilapidated wheelchair with a cup in one hand and a hand-lettered sign in the other. I smiled as I walked past this gentleman because he added an exclamation point to my afternoon’s journey. On his sign was a quotation from FDR that I had seen at the memorial: “The test of our progress is not whether we add more to the abundance of those who have much, it is whether we provide enough for those who have too little.”
The irony of the homeless man holding that sign in the shadows of the tertiary care hospital was not lost on me. The incongruity of the scene helped me recognize that I had gained “a new understanding of the world” and that I had a duty to use the truths I learned “for the common good.” I left a generous contribution in the man’s cup and went to my meeting with a new perspective and a clearer purpose. MM
Edward Ehlinger is a pediatrician and internist and is the director and chief health officer of Boynton Health Service at the University of Minnesota.