A young woman stands in the freezing cold outside an urban Baltimore hospital. The woman, covered only by a thin hospital gown, moans incoherently at the man capturing her suffering on cellphone video. As seen on the now-viral video, she’d been left there by security personnel employed by the supposed place of healing just a few yards away. It hurts to watch.
Mass media outlets are appalled. Where‘s the empathy? Another failure of our “broken healthcare system” and a screaming example of inequality on every level (she’s poor, female, African-American, and mentally ill). Case closed in the court of public opinion.
But those of us on the front lines working in our nation’s safety net hospitals don’t get to talk about the details of cases like this due to patient privacy laws. So let’s speak using the hypothetical “what if?”
What if the staff of this inner city hospital in a heavily impoverished area with a high crime rate, high drug abuse rate, high mental illness rate, and high rate of homelessness needed to deal with “frequent fliers” (patients who repeatedly use hospitals to satisfy basic needs for food, shelter, medicine, or other attention) on a daily basis?
What if many of patients at this institution had long complicated psychiatric and social histories, and as such are well known to multiple hospitals in the area?
What if this poor woman had suffered since childhood with mental illness and developmental delay, making it nearly impossible for her to function in society without help? What if there were a history of belligerence and violence towards healthcare staff and nonadherence with care plans, either for admission to the hospital or discharge to cold shelters? What if the ER, already quite busy trying to handle numerous other emergencies, determined she did not meet criteria to be admitted?
A lot of armchair psychiatrists are screaming, “It’s clear this woman should be in the hospital. She’s crazy and not competent to care for herself,” forgetting that mental status can wax and wane very quickly, and while being evaluated one’s competency is judged during a discrete time period by professionals (as opposed to a few minutes of cellphone video taken on the street). What if it’s also against the law to hold a patient against their will unless they demonstrate during the evaluation period that they are a danger to themselves or others?
What if this woman did not meet those criteria during evaluation, was offered a transfer to a shelter and refused, had burned her bridges at other shelters, and burned her bridges with family and friends?
What if there was violence on the part of the patient, with altercations and refusal to follow commands in the hospital after discharge, ultimately leading to an escort by multiple security personnel due to the strength and potential danger she posed to the staff? Let’s hypothetically imagine that this is what happened. Should she have been thrown out into the cold in nothing but a gown?
What if we added another “what if”…
What if she was given all her clothes and told to dress but refused to do so. What would you say then? Would you say, “Could it be her mental illness? Or could it be that she made a choice? Could it be that the security guards made a mistake, having dealt with so much belligerence and so many difficult patients?”
We don’t know. But here’s something that isn’t hypothetical: this case is a picture of disaster from start to finish in a city struggling with poverty, with difficult race relations, with inequity, with mental illness, with homelessness, with substance abuse. We shoulder our institutions of healthcare with the burden of solving the upstream societal problems that our pathetic, short-sighted political leaders have lacked the courage and human decency to address. We medicalize our social problems in the US, and then scream accusations at our frontline healthcare workers who are tasked with doing the impossible despite burnout, physical risk, daily humiliation and constant devaluation.
We look to our hospitals, to our doctors, to our nurses, to our respiratory therapists, to our social workers, to our psychiatrists, to our case managers, to our discharge planners, to solve the problems that we’ve been collectively too craven to solve ourselves. Then when a tragedy like this is documented on video (and this is just the tip of the iceberg), we ignore our failure to manage the root cause of the problem, instead pointing at the nearest scapegoat. People are outraged at the emergency department. Yeah, you should be outraged. You should be mad at the emergency department for failing in the face of impossible odds. But you should be furious at the larger system that failed this woman and hundreds of thousands of others like her who suffer daily.
What if we as a society addressed the upstream causes of homelessness, poverty, inequality, and chronic disease? What if we funded mental health care and provided safe housing and support for those in need? What if we shifted some of the 3 trillion dollars now wasted on ineffective downstream healthcare towards that very end?
Zubin Damania is an internal medicine physician. He can be reached on ZDoggMD, on Facebook and at Twitter @ZDoggMD.
Image credit: WDBJ7.com