Original Research Paper

Human dignity: a framework to understand and respond to COVID’s disproportionate effect on vulnerable populations

Anthony Fleg ¹, Jamal Martin ², and Amy Clithero ³

¹MD, MPH, Associate Professor, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, United States

²PhD, MPH, Associate Vice Changcellor, African American Health, Office of Community Health, Health Sciences Center, University of New Mexico, Albuquerque, United States

³PhD, MBA, Principal Lecturer, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, United States

ABSTRACT

Background: The COVID-19 pandemic and the increased emphasis on recognizing and dismantling systemic racism provided an opportunity to use the human dignity framework for a small-group workshop during the 2020 and 2021 UNM School of Medicine orientation. The objective was to see if this framework effectively taught students about Social Determinants of Health (SDOH) and caring for vulnerable populations, locally and globally. Methods: In a small-group setting, we introduced the concept of human dignity and then applied this through two case studies. We surveyed students following the session. Results: Post-session evaluations reflect increased students’ self-reported understanding of social determinants, exposure disparities that may affect one’s risk of contracting COVID-19, and their confidence that students and clinicians can significantly impact addressing SDOH for vulnerable populations. The course was also influential in helping students feel comfortable with their peers and served as a welcome to the medical school. Discussion: The human dignity framework effectively taught students about the social determinants of health and caring for vulnerable populations. This moved us away from politicized realms and into a constructive learning environment useful for medical education and global health education far beyond the pandemic.

Keywords: human dignity, social justice, COVID, Social determinants of health medical education

Introduction

Human dignity as a theoretical framework can assist in creating and sustaining a culture of health equity in health professional schools. One definition of human dignity is that all people hold a special value that is tied to their humanity.¹ Over the last almost 30 years, the concept of human dignity has been incorporated into health policy, global health, and international documents. Examples include the 1997 United Nations’ Universal Declaration on the Human Genome and Human Rights,² where protecting human dignity is a core theme of the document, and the 2008 “Closing the Gap” report of the World Health Organization Commission on the Social Determinants of Health (CSDH) where addressing SDOH inequities is framed in the concept of health as a human right.³ As noted by Kenyon et al., “Since then, there have been several critical global policy initiatives…which affirmed the links made by the CSDH locating the SDOH in relation to human rights and the right to health.”⁴ Human dignity is what we are protecting in efforts to frame health as a human right.

Most people intuitively “understand” human dignity, but when theory is linked to actual clinical practice, it becomes a concrete, actionable step in the pursuit of social justice. When social justice is distilled to actual persons maintaining their dignity, action becomes more imperative. The framework of human dignity helps move learners from theory to practice in social justice.

Moreover, given the politicized nature of the COVID pandemic, we hoped that human dignity would allow us to discuss its effect on vulnerable populations more effectively. In our session with students, we focused on three core aspects of human dignity:

• Representation → People feeling seen and represented in institutions
• Agency → People having a choice and chance to consent to the decisions being made about their lives
• Health Equity → Working to reduce inequities in health, recognizing such inequities as conflicting ethically with the right to health as a human right

When “Health of New Mexico,” a social justice and population health-oriented two-week course at the beginning of medical school at the University of New Mexico, was postponed due to COVID, a group of faculty committed to health equity decided to create new content that maintained this unique part of our curriculum. We used this moment as a chance to infuse the framework of human dignity into the learning.

We structured the session to reflect two realities— the COVID-19 pandemic and two vulnerable populations in our state: individuals experiencing homelessness and American Indians. Regarding the latter, New Mexico is home to 23 Tribal Nations, comprising 10.5% of the New Mexico population.⁵ In the early months of the pandemic, both of these populations suffered disproportionately from COVID. For example, as of June 1^st, 2020, 58% of COVID cases in New Mexico were American Indian citizens.⁶

For our pedagogical framework, we chose to deliver content using Interactive and Constructive learning activities described by Chi et al. to enhance learning.⁷ We utilized small group sizes to maximize interaction between students and facilitators.

While there is significant literature on teaching SDOH in medical education, the approach of using human rights and human dignity as a framework for understanding and addressing inequities in health appears to be much less utilized.⁸

The objective of this study was to see if this framework was effective for students to learn about SDOH and caring for vulnerable populations, locally and globally.

Methods

Curriculum Development

The authors of this paper worked over a period of one month to develop the content and flow for this session. The two case studies were developed by clinicians with extensive experience working with the respective populations, including those experiencing homelessness and Native American communities. The faculty worked with the Office of Medical Student Affairs on logistics since this session was held as part of the Medical School’s orientation week.

Implementation

This was implemented virtually (using Zoom) with the first-year medical and physician assistant students at UNM in July 2020. The sessions took place in person in the subsequent year, July 2021. Both years used a 45-minute block of time. In 2020, after a brief welcome to the session, with objectives for the session stated and brief introductions from the faculty, we broke students into groups of 8–10 students and one faculty member per group. In 2021, the session had no large group component and started with faculty in their rooms of 8–10 students. We felt these small groups would allow for more meaningful conversation and a less intimidating environment than large-group learning. The session was divided into three sections, in the facilitator guide, and the PowerPoint presentation.

Introductions – 10 minutes

The faculty described group norms and discussed this as a vulnerable, safe, and honest space. The faculty then shared insights on the impact of COVID-19 on them, choosing whether to share from their professional or personal realm. Each student then introduced themselves, including the impact COVID-19 had on them.

Introducing human dignity – 15 minutes

Introducing students to the framework of human dignity.

Applying human dignity framework through case studies – 35 minutes

Evaluation

To assess our novel curriculum, we surveyed students immediately after the session’s completion using the UNM SOM email system and Survey Monkey evaluation with a Likert scale, 0–100 scale, and open-ended questions. The UNM Human Research and Review Committee exempted this study (HRRC #20-667)

Results

All 107 medical (MD) and 17 physician assistant (PA) students matriculating into UNM in July 2020, and all 107 MD and 17 PA students entering July 2021 experienced our educational activity. We had a 57% response rate in 2020 (N, 71) and a 70% response rate in 2021 (N, 87) to our survey.

There were six facilitators: four physicians (three in family medicine, one in pediatrics) and two PhDs, all with direct experience working with vulnerable populations in rural and urban settings. All facilitators are passionate about addressing the social determinants of health (SDOH) and including this in medical education, and all are experienced small-group session leaders.

Quantitative data

Two of our evaluation questions utilized a 100-point Likert scale, where 0 was labeled “I have no understanding,” 50 was labeled “I have a basic level of understanding,” and 100 was labeled “I understand it extremely well.” The 2020 students’ self-reported understanding of how social determinants of health affect one’s risk of contracting COVID increased from 65 before the session to 82 after the virtual session. The 2021 students who experienced the course in person showed a change from 70 to 85 on the same measure.

Another set of two questions utilized a 100-point Likert scale to gauge confidence, with 0 labeled “not confident,” 50 labeled “neutral,” and 100 labeled “extremely confident.” Self-reported confidence that students and clinicians can make a significant impact in addressing SDOH for vulnerable populations rose from 59 to 77 on a 100- point scale (2020) and from 64 to 82 (2021) for the two cohorts.

We also looked at how effective this session was in helping students feel comfortable with the UNM student community in the PA and MD programs, with 86% reporting “effective” or “very effective” in the 2020 cohort and 93% in the 2021 class.

Finally, 96% (2020) and 97% (2021) of students reported the session was either “effective” or “very effective” in welcoming students to our UNM Medical School MD and PA programs.

For the purpose of obtaining results related to the two aforementioned questions, we placed a value of “effective” on the unlabeled option between “neutral” and “very effective.”

Qualitative data

We also asked two questions of our learners in 2020 and 2021, eliciting students’ thoughts on the value of this session. The same questions were used for both years.

Question 1: What are 1–2 key takeaways for you from this session?

Question 2: Please share your thoughts from this prompt: “As health professionals, recognizing human dignity is expressed by working toward equity in health (e.g. the elimination of all health inequities), assuring that all persons and communities have equal access to health.”

Students responded to both questions with a depth that is not captured by the above quantitative data, and we included examples that illustrate the overall themes

To question 1, here is a student response that reflects the “takeaways” that many students expressed:

I learned that we should always ask patients and communities for input on changes placed to improve their safety, such as the Navajo community and the COVID pandemic. I also learned about SDOH and how these shape the health of a person due to factors such as poverty, lack of access to transportation or healthcare facilities, education, access to water or electricity, amongst many others.

Regarding question 2, asking students how they tie human dignity and health equity, students spoke passionately about this connection and how they want to make this a focus for their work as physicians. Here are two quotes that illustrate the larger theme.

We grant dignity to others and we recognize their rights as humans when health care access and equitability is paramount.

I really appreciated the focus on this statement during the COVID presentation and Social Determinants of Health presentation. It’s so important to address inequities.

Of note, there were no comments to question 2 that did not express agreement, but some students wanted to make points they felt needed to be included in the session. Here is an example:

I agree with this statement but I just want to elaborate that creating equal access to health does not only include changes to the healthcare system. Just because healthcare is free to everyone does not necessarily mean that it has equal access. We must also consider things like transportation, time, and the overall culture of healthcare that may prevent potential patients from coming in. Addressing health inequities from multiple angles is required to recognize human dignity.

Discussion

The framework of human dignity effectively allowed students to understand and respond to COVID-19’s disproportionate effect on vulnerable populations, both locally and globally. This novel approach moved us away from politicized realms and into an effective learning environment that we feel is useful far beyond the pandemic for medical education. Focusing on the three tenets of human dignity allows students to develop concrete plans that address representation, agency, and health equity as they work through case studies. Going into this session, facilitators worried that this session’s content may not be well-received given that it was done during medical school orientation, a place usually reserved for getting to know the school, and not one where medical content is introduced. However, the data shows that this session effectively welcomed students to the school. When we compared the virtual (2020) and in-person (2021) versions of the course, where all attempts were made to keep the content and cases the same, we did not see a significant difference between the two cohorts concerning their evaluation of the course. This suggests that the course will be effective in either setting.

We suggest health professional schools implement similar content about human dignity applied to vulnerable populations during orientation. This is not only an opportunity to begin professional identity formation around such social justice issues, but it also builds a sense that clinicians are a group invested in upholding the human dignity of those they serve. In addition, placing human justice at the beginning of their education reinforces its importance as a critical concept. We also suggest using a case-based approach using their community issues to make situations “real” and include concrete examples of how practitioners addressed the issues in real-time. This assists in moving students from the purely theoretical stance to realizing there are practical steps they can and should take to address population health problems and address disparities.

1. WHO Commission on Social Determinants of Health, World Health Organization, eds. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report. World Health Organization, Commission on Social Determinants of Health; 2008.

2. Universal Declaration on the Human Genome and Human Rights Accessed August 28^th, 2024. https://www.ohchr.org/en/instruments-mechanisms/instruments/universal-declaration-human-genome-and-human-rights

3. Closing the gap in a generation: health equity through action on the social determinants of health - Final report of the commission on social determinants of health. Accessed August 28^th, 2024. https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1

4. Kenyon KH, Forman L, Brolan CE. Deepening the Relationship between Human Rights and the Social Determinants of Health: A Focus on Indivisibility and Power. Health Hum Rights. 2018 Dec;20(2):1–10. PMID: 30568397; PMCID: PMC6293351.
PubMed  PMC

5. Census Data from New Mexico Tribal Communities | NMEDD. Accessed August 30, 2020. https://gonm.biz/site-selection/tribal-profiles

6. NM-IBIS - Health Indicator Report - Deaths from COVID-19 by Race/ethnicity, 2020. Accessed September 22, 2022. https://ibis.doh.nm.gov/indicator/view/COVIDDeath.RacEth.html

7. Chi MTH, Wylie R. The ICAP Framework: Linking Cognitive Engagement to Active Learning Outcomes. Educational Psychology. 2014;49(4):219–243. doi:10.1080/00461520.2014.965823.
Crossref

8. McKenzie, K. C., Mishori, R., Ferdowsian, H. (2019). Twelve tips for incorporating the study of human rights into medical education. Medical Teacher, 42(8), 871–879. https://doi.org/10.1080/0142159X.2019.1623384
Crossref  PubMed

© Education for Health.

Education for Health | Volume 37, No. 4, October-December 2024

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