In harm’s way…


Today, despite my being an ocean away, like most Americans I was transfixed on the unfolding events in Dallas, Texas. During the week I had heard news reports of 2 black people being killed by Police in various parts of the US. I didn’t pay much attention; to me it is not news. I spent a good many years working rough neighborhoods in the US, and the reality of the situation is poor people, irrespective of color, have the most interactions with police.

While we could theorize why this is ad naseum, it has been my observation all over the world, that the culture and reality of poor people simply does not permit them to act or hold the same values as middle and upper class citizens in their respective countries. In many cases, trying to cope with the mental and emotional stress of their situation leads to the use of drugs or alcohol; not because it is a positive coping mechanism, but because it is the only one available or practical to them. Being from a poor family myself, I know very well about “recreation” being low wager (penny, nickel, dime) card games with alcohol and cigarettes being the way families relieved stress and bonded with each other. I have worked in areas so poor that getting high, more high stakes gambling, in the form or larger amounts or even property items were gambled for an attempt at survival. Prostitution and violence naturally becomes a part of this world of law of the jungle survival.

Many people in middle or wealthy communities simply cannot imagine what it is like to need to prostitute, gamble, or use/react to violence is required not only to protect what little they have, but for very survival. During my time in urban inner-city US, I interacted with girls who in exchange for a place to sleep, protection from violence, and a chance to pool resources were trading reproduction (aka becoming pregnant) in order to secure the aid of males for these endeavors. I wonder how many women reading this can imagine having to have a baby at 13 or 14 years old in exchange for a place to live, food, and protection? It is reality for many, both in the USA and out in 2016.

The “leaders” of society, and even many in the middle and upper classes are oblivious to this level of existence. In the effort to secure their own security, in the form of money, resources, reproductive rights, and security, they essentially legislate their morals and culture into law. This means anyone not behaving or acting like they would are criminals. However, this does not take into account cultural differences or the practical aspects of surviving. It essentially transforms being poor into a criminal social class. When a person’s very basic behaviors for existing are considered criminal, they must choose between crime and death. An unfair choice, and almost certain to draw the attention, and eventually frustration and ire of law enforcement.

In the modern USA this is exacerbated even further. Being poor has been made culturally distasteful, to the point of outright contempt for poor people by upper classes. Add to this that they have already been legislated into being criminals and they are effectively dehumanized. Police fire and EMS responders, spend a long time, in fact most of their time staring into the abyss this poverty creates. My favorite philosophical quote, which I find myself using often is such:


Unfortunately, as many public servants, specifically Police, Fire, and EMS are drawn from middle and upper class, and in many cases actually create middle and upper class employment, many of the providers do not understand, or even recognize the cultural and basic requirements these poor need for survival. They begin to resent them, but their lack of engagement also makes them fearful. When working in such neighborhoods, they often do not understand the culture. They cannot differentiate aggressive behavior or threatening behavior of the culture they are in. It is for all intents and purposes like going to a foreign land for them. The perception and many are even educated to the idea, they are constantly under threat. What absolutely baffles my mind is the fact we know PTSD can be brought on by being constantly under threat. The US Army manual of psychiatry lists indirect artillery as the most mentally stressful event a soldier can undergo in combat. Even healthy soldiers have been driven to suicide from being shelled. For all intents and purposes, an acute psychiatric event. The manual goes on to say that the explanation is because they cannot control any aspect of the event that might harm or kill them. If this is true, and it seems to be, it has considerable implications on public safety forces working in poor environments. In the US military, combat tours are generally restricted to 12 months. 12 months of being under constant stress, even if the stress is higher, is not the same as years of being in an unfamiliar environment, that is not understood, or controlled. This is the reality many public service officials, particularly Police, Fire, and EMS make a career out of!

(no idea why the font suddenly changed) About 10 years ago, I started studying anthropology, particularly biological anthropology. One of my professors was a world renowned expert in forensics, and he often professed that “all anthropology is cultural.” From this education, I started viewing my own job and interactions with people through this lens. Conclusion? People are animals, all people are. We cannot escape our manipulate ourselves to not protect “home range resources” which consist of the the resources like food, shelter, reproduction, and environmental space we simply cannot live without. In fact, any primate, and many animals will die defending this home range because they will certainly perish without it. Modern humans are no different. From there we start to gather and protect our excess. You can see where this instantly puts poor people, who are at base home range resources in conflict with wealthier neighbors who are expanding their resource share past their home range. One simply cannot lose more, the other wants to gain and protect more.


During this time I was also trying to use my new found anthropology information to more effectively provide medical care to the populations I served. Through much research, I discovered than the urban poor of the US shared similar characteristics to refugees in foreign lands. In fact, even the paleopathology and disease cycles are exactly the same. They both suffer through cycles of acute traumatic injuries, followed by the effects of a depleted and inhospitable environment. For perspective, it means there is violence to secure resources in a depleted area, followed by the effects of not having enough resources, returning to the violence needed to secure what there is. I suspect that is why the inner-city poor in the USA continuously see outbreaks of violence followed by periods of relative calm (relative meaning base level of violence as opposed to a heightened quality or quantity), where politicians and activists then ignore the uninhabitable environment, which then triggers escalated violence again.

So detailed was my study into this, I was actually invited to speak on the topic at a University detailing how this affected the provision of medical care to poor populations.

This increased violence and fear by public servants working in this “foreign” environment causes the need to focus on personal protection. In short, escalating the level of violence to be greater than what it witnessed, as well as preempting violence upon the civil servant by first enacting state sanctioned violence on the civil inhabitants. Some call this the “militarization of the Police” and there is a lot of truth to that. But we are now also seeing the militarization of others, such as EMS and Fire.

Because these professions can hide behind the cultural value of being protectors, selfless, and even heroes, it further alienates then from the people they “serve” or at least interact with. They become not only an economic class, but a privileged social class.

The Police in particular seem to more and more become the agents of a repressive and openly hostile State against these poor people, who I already discussed, are legislated to a criminal class. They seem themselves as the protectors of society from evil and anarchy, but in fact are simply the point of the spear for the oppressors.People within a society are being forced to choose whether or not they support the “law enforcement” or “poor people.” Essentially, “If you are not with us, you are against us!” This absolutism causes further conflict. It sets the stage for violent confrontation.

But this blog is not about politics or socio-economics, it is about medicine. I merely have to describe all of this to set the stage for what I really want to talk about.

How do we provide medical care in such a climate?


A few years back, I was invited, and actually paid to go teach a medical class in Kyiv, Ukraine. It was before their revolution and subsequent war. Despite there being no open signs of fermenting unrest, there were paramilitary police everywhere. Ostensibly for “maintaining law and order.”

Despite that being my only connection to the country, and the fact I live in a bordering country, when their latest revolution broke out, in a spot I had personally stood and admired the beauty of just a few years prior, I was compelled, even obsessed with knowing what was happening, and why. I cannot explain it. But I watched it live as often as I could, I read all the news reports from both sides, and I saw and still affected by the law enforcement activities I witnessed. What scares me more, is I observe the exact same situation being set up in the USA today. The thing that disturbs me the most of the “militarization” of US police are not the weapons, the armored personnel carriers, or even the fact many are prior military service. What disturbs me is the adoption of military tactics as the first resort.

Yesterday in Dallas, police used a robot carrying a bomb to remotely kill a sniper. Today it is reported in news here, the sniper was a prior serviceman in the US Army, who is believed to have seen himself as defending citizens of the US from a police force perceived as an oppressive domestic enemy. Police use of force experts were quick to defend the action saying that once the use of force has been authorized, the form it comes in doesn’t matter. In that case, why a drone carrying a bomb? Why not indirect artillery? An airstrike? A Flamethrower?

What has this to do with medicine or Ukraine? In modern Military tactics, medics, or medical providers are in the top 5 targets often considered valuable to snipers. The person in Dallas was using sniper tactics. That means medical providers both at a scene, as well as remotely, at hospitals, may be purposefully targeted.

The next question remains, targeted by Who? In the US, medics, and all forms of healthcare have cultivated close associations with law enforcement. Some providers and even agencies take it upon themselves to act as an extension of law enforcement. Logically, that makes them targets of people feeling oppressed by the State. Essentially in creating such an integral relationship between medicine and law enforcement agents, medical providers have surrendered their neutrality. Every day, we already see an increase of violence against providers, with the reaction to further define them as a protected social class legally. Healthcare providers, particularly EMS are beginning to emulate the tools, techniques, tactics, and mentality of paramilitary law enforcement.

What that exactly means if disaffected classes start drawing lines of “us” and “them”, we are a “them”, and can expect to be treated as such accordingly. This is reinforced with behaviors like standing next to or even embedded with law enforcement. . I am not sure painting a giant target on oneself makes one “safer”.


So what happens to medical providers who choose to help “the other side” during times of upheaval or civil unrest? How will they be identified? Will protected symbols such as red crosses be respected by an opposing paramilitary police force? Will law enforcement treat them as “the criminals” or “the enemy” if these MEDICAL providers are rendering care and not standing with the Police? Will Police snipers find them to be inviting targets to “teach them a lesson” or to “demoralize” their opponents? These are both common military tactics. Will law enforcement impede provision of care to the wounded or sick by interfering with these providers, arresting them, or otherwise forcibly removing them? Will they be considered “collateral” damage if they are injured by area of effect or direct weapons? There are dozens of confirmed videos of Ukrainian law enforcement directly targeting medics with sniper fire. Even destroying medical equipment and aid clinics seen as “friendly” or “part of” the rioters.

What stops that in the USA?

From the practical aspect of the “other side” how to providers ensure their own safety and still help? What level of safety is tolerable or even expected? What is the potential fallout of being seen “not to help” in the aftermath, the short and long term?

Many modern US EMS leaders are adopting practices that have been around in Europe for ages, particularly that of rendering aid during active shooter incidents; all of the scenarios being considered and trained for, make several assumptions not shared by civil unrest in refugee conditions.

Those assumptions include, but are not limited to:
-Being protected by law enforcement

-Being “On the same side” as law enforcement

-The establishment of “hot”, “warm”, and “cold zones” which are largely identified and static
-That the people being aided see EMS as help, and not an enemy
-That EMS will not be victims of mob mentality if seen as not helping which may erupt spontaneously

– That only EMS affiliated healthcare providers will be rendering aid

-That transport or evacuation is always readily available or possible

-That the incident will be of short duration and not days, weeks, or months

-That mutual aid or outside resources will be readily available

This carries on into the hospital. Fortunately for hospitals, most of the concerns are similar to any large scale disaster. Security, resources, consumables, managing human resources, need to evacuate the facility, etc.

There will also be concerns of the need for out of hospital first aid, triage, or treatment posts staffed by providers who do not traditionally function in such a role.

In the US, what about the economic impact to hospitals and providers of large amounts of people above normal requiring emergency aid and ultimately unable to pay?

What care will even be available? At what level? How long can a facility operate beyond a short term surge if the event draws out weeks or months?

It seems to me at least, observing from the outside, the US is reaching its tipping point of wealth management as well as social fabric. It seems to me the leadership is totally disinterested in taking any steps to remedy or even deescalate the situation. In fact, it seems law enforcement is absolutely bent on escalation in the name of maintaining law and social order. But for all of this, none of it changes the fact that medical providers will be called upon, even expected to treat the sick and injured. It seems apparent that current plans as well as assumptions will not be viable.

What is certain is medical and other healthcare providers may have to redefine how and with who they function in conjunction with. Otherwise perceived lack of neutrality from any side will certainly result in not only increased risk, but increased harm. Choosing a side in “us” vs. “them” is a losing strategy for medical providers. Protected neutrality must be the goal in both practice as well as perception.

That is a fundamental shift from current practice and thinking.

PS. Please refrain from posting comments stating “I am either with you or against you” or some other idiotic absolutism.