When I first got involved with Fire and EMS, it was in a middle class suburb. That morphed into an upper class suburb, went into small towns, and eventually led to poor areas like the inner-city and rural America.
The morning of my first full (and busy) night in the ‘hood, just before shift change, there was what at the FD we call a “still alarm,” aka somebody walked up and rang the doorbell. She announced to us that she had just overdosed on crack cocaine. We led her into the station and sat her on the tailboard of the truck. As we went about assessing her, I found myself with the IV supplies and searching for a vein. I found a sliver of the median cubital vein in her left arm. (The term antecubital refers to the surface anatomy, not the vein) As I began the alcohol prep (we did not yet have chlorhexidine) she looked at me and said “oh honey, don’t use that vein…I save that for when I score some morphine.” Without a pause, one of the most capable and experienced fire/medics I ever met looked at her and said “Do I tell you how to smoke crack? No. Don’t tell him how to do his job!” Judging from his next comment I probably had a very incredulous look on my face. “The mayor will not be right down to this neighborhood to tell me to be nicer to people unlike in those suburbs you came from…” With the structure fire the previous evening, extricating the body out of the trunk of a car that was set on fire to cover up the homicide, learning that I could really say what was on my mind to the patients, I knew I was where I belonged, in the eye of the storm.
For my next job (my first EMS only job) I told the hiring manager I wanted the busiest station in the ‘hood and I would accept no other assignment. He looked at me and after a long pause, in a very low voice, said “Nobody has ever asked for that before. In fact we have trouble even staffing that station, it is one of the busiest in the state.” So after agreeing that assignment was a condition of my employment, he gave me directions to get there so I could go and meet my coworkers before I started.
When I got there, I was not surprised to find a station full of the most capable medics in the US and probably the world. They were certainly not the corporate poster boys and girls. We had good times and more than a few stories that are stranger than any fiction ever written.
Upon returning to my home, I had a brief period of employment with a company that was staffed by a bunch of small town yokels who thought they worked in a ‘hood. I lasted about a month before I was back in the ‘hood where I belonged.
But aside from perhaps being “tainted” and losing most of my diplomatic skills or even desire to have diplomatic skills, I came to really understand what it means to be an inhabitant of this socio-economic environment. They face a reality similar to war. There are never enough resources; people do what they must to survive. Education is more of a luxury than a requirement. Death is an everyday fact of life. Laws are made by people who have no connection to this world, and enforced upon its inhabitants with no regard to their reality at all.
This leads them to not only have an innate distrust of authorities, but it also subjects them to the criminal justice system very frequently which further exacerbates their poverty and crushes their social mobility. It means when women who are prostituting themselves on street corners get picked up by the law, not only do they have to live with selling themselves for money, often taking drugs to cope, but the money they gained from it pays bail and a court fine instead of putting food on the table, cloths for school, or gifts under the Christmas tree; the same for drug trafficking offenses and a host of other “moral” crimes.
Here in Europe I have witnessed a similar pattern in issues revolving around gypsies and more and more other poor and disadvantaged people of more traditional and national populations. It has been made shameful to be poor, but not enough resources are allocated to break the cycle of poverty. All the while the rest of us lounge in Starbucks and eat Sushi delivered to our door, while planning our next vacation abroad.
This all sets the stage for what is bothering me:
Healthcare providers who treat the poor and destitute with contempt.
“You called the ambulance at 3am because your kid has a fever?!” Yes, they did. They are not educated healthcare providers. They are scared because they don’t know what to do and actually care about their kid. So they called for help. But often instead of using this opportunity to teach and explain, they are berated and told they improperly used the EMS and ED. Then when I question healthcare providers why they didn’t educate the patient or family, they claim it is too much of a risk because they will be responsible if the kid gets a fever and the family doesn’t come to the ED because it may not be so simple next time. (If you don’t see the hypocrisy in that read it again.)
The same is done to sex workers who are pregnant, have STIs, or were assaulted/abused. The same happens to the alcoholics and drug abusers who are self-medicating themselves for a host of stressors of their life. Going to the psychologist for some talking sessions doesn’t change their problems or their stressors. Here, like in the US, there is less of a stigma being a drunk than being crazy. Many of these people fall through the gaping holes (not to be confused with cracks) in social support systems. Here, some don’t even have their paperwork filled out for their government provided healthcare. In the US, the situation is much worse for the poor; especially the working poor, who may have no access to healthcare or social support at all. Even if they are eligible, they will be socially ostracized for being “lazy,” etc.
Yet healthcare providers of all types are quick to express to these people how distasteful they are at every opportunity? They are quick to berate and cast judgment upon them for their choices, giving no thought or reflection that they do not have the same choices we do. This animosity is amplified if the person in question is an immigrant or asylum seeker.
So how did people who usually get into health fields to help people become so critical of people who need the most help? How can this be changed? Education? Peer pressure? Mandatory time working with the underserved? Since we cannot change the reality of the poor, we must change our perception of them. We must remember that we want to help people. That implies all people, not just the ones we find desirable. Strangely enough, the most positive impact comes from efforts to help the least capable. They do not live in our world. We cannot hold them accountable to our morals and desires. This problem is endemic in medicine today. It will not be quickly or easily solved.
One thing is for certain, we must move in a different direction than we are going. We must become less of “professionals of high society” and go back to our roots of being non-judgmental and trusted friends and advisors. Strangely enough, this seems to be the exact same problem and solution that is being addressed by the current pope in regards to clergy. While it may be a sickness of society and not just healthcare providers, we must be the leaders for change.