My White Patient Needed Anti-Racist Advocacy
“If Black women were free, it would mean that everyone else would have to be free since our freedom would necessitate the destruction of all the systems of oppression.” — Combahee River Collective
“‘The firemen said there were little fires everywhere,’ Lexie said. ‘Multiple points of origin. Possible use of accelerant. Not an accident.’” — Celeste Ng, Little Fires Everywhere
During my internal medicine rotation in my third year of medical school I was taking care of a patient who was going through alcohol withdrawal. Like many patients struggling with alcohol use disorder, this admission was one admission among many for the same issue. Withdrawing from alcohol can be life threatening which is why this usually leads to an inpatient hospital stay. Patients usually know this, especially if they’ve gone through severe withdrawal before, which can lead to seizures, hallucinations, delirium tremens and death without treatment. On the bright side, this was the first admission in many months for my patient because she had gone through a significant period of sobriety. When she did relapse, she knew that she needed to reach out for help and appropriately called emergency medical services while intoxicated. As documented by staff in the emergency room, she, along with her belongings, were brought in by emergency medical services in the early hours of the morning.
The general treatment plan for alcohol withdrawal is to monitor for symptoms of withdrawal and if present, administer benzodiazepines, which bind to the same receptor as alcohol. This eases people through withdrawal while preventing the severe effects of sudden abstinence. It’s as if these patients are in a highly flammable house and if a small fire starts, we need to extinguish it quickly or else everything could go up in flames. The most dangerous period is within about 48 to 96 hours during which patients are monitored for early signs of withdrawal including anxiety, tremors, sweating, nausea and vomiting, or headaches. These signs are like the little fires we put out with benzodiazepines to prevent the inferno of seizures, delirium and death. Slowly, my patient’s physiologic alcohol withdrawal induced anxiety abated, but another source of anxiety quickly set in.
A few days into this patient’s admission. I went to see her in the morning before rounds only to find she had been visited in her room by the hospital campus police force and issued a $530 ticket (the extra $30 for a processing fee) for possession of alcohol despite being brought in with her belongings by emergency medical services. Review of the emergency room notes showed that shortly after she arrived what was found in her bag was poured down a sink by staff, which could have been the end of this story. Instead, the police waited until she was more sober and stable to show up to her hospital room and ticket this person who called for help with her alcohol use disorder.
The American Public Health Association in November of this last year officially adopted a policy of addressing law enforcement violence as a public health issue. While not an instance of direct physical violence, this was an instance of harmful law enforcement. The 8th amendment of the U.S. constitution states, “Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.” When nearly 40% of Americans can’t afford an emergency $400 expense a $530 ticket for possession of alcohol is excessive and cruel in the context of someone seeking treatment for alcohol use disorder. She may have to choose between paying the fine and paying for rent, bills or food. She may lose work for having to show up in court. If we didn’t stand up for her, we could lose her trust. If she were to relapse again, she may hesitate to call us for help and she might end up trying to go through withdrawal on her own. This could kill her. Who, though, would stand up for my patient?
The only power I felt I had as a medical student was to be vocal. One of the worst parts of this experience was hearing my supervising resident physician tell me that there was nothing we could do. What he really meant was it’s not my problem and I don’t care enough to make it my problem. Instead of letting it go, I raised my concerns with other residents and attending physicians. Only one doctor told me that this was something that we could make go away via direct discussion with the medical director of the institution, who apparently had the capacity to waive tickets like this. So, I knew it was possible with enough power and privilege. I waited to hear back from the other physicians, but my time on this rotation ran out and I had to leave. I never did hear what ended up happening.
My standard clinical education did not prepare me to speak out for my patient like this. The framework that allowed me to advocate for my patient was based in anti-racism and critical race theory. What on the surface appears to be an interaction with a police force and a white patient in the hospital, is deeply rooted in racism. This stems back to the Nixon administration directly targeting Black people in antiwar leftists in the war on drugs and the war on crime, with harsh policing and sentencing sparking the dawn of mass incarceration. A background in critical race theory allows us to recognize and disrupt injustice within our institutions and mitigate harm to our patients, regardless of their race. If the physicians at the hospital collectively understood this history and embraced anti-racism, more of them would have spoken up and the ticket would have quickly been erased. Even better, there would have been hospital policies preventing the police from prescribing punitive fines for substance possession, especially for patients suffering from substance use disorder. This never should have happened, but our silence allowed it.
I should not have to advocate for anti-racism using the narrative of a white patient. Beyond disparity statistics, there are countless narratives of racism in medicine that result in our patients of color losing their lives. But, as Ryan White and our response to the opioid epidemic compared to the crack epidemic have shown, these issues are not taken seriously until they affect normative white communities. While there is no such thing as reverse racism¹, racism as an institutional structure certainly impacts and harms white people like my patient. Still, we use a framework of racism because our Black patients, indigenous patients, and other patients of color are historically oppressed and disproportionately affected by superficially colorblind policy. Medical students, residents, physicians and health professionals at all levels need to be able to see how medicine participates in structural racism, both historically and to this very day. Colorblind curriculum in medical education is permissive of harm particularly for patients of color with white patients as acceptable collateral. When you open your eyes, you find the fires of racism and oppression are burning everywhere. It’s on all of us to put them out.
- Reverse racism does not exist, just the same as reverse sexism does not exist because racism and sexism are not the same as prejudice. While women can be prejudiced towards men, they cannot be sexist towards men because they do not hold the same political, economic, and social power. For a visual representation, this is what politics looks like when men are removed from the photos.
For more reading on the work to do:
Hardeman, R. R., Medina, E. M., & Kozhimannil, K. B. (2016). Structural Racism and Supporting Black Lives — The Role of Health Professionals. New England Journal of Medicine, 375(22), 2113–2115. https://doi.org/10.1056/NEJMp1609535
Metzl, J. M., & Roberts, D. E. (2014). Structural Competency Meets Structural Racism: Race, Politics, and the Structure of Medical Knowledge. AMA Journal of Ethics, 16(9), 674–690. https://doi.org/10.1001/virtualmentor.2014.16.9.spec1-1409.
