About a year ago, the National Rifle Association (NRA) tweeted an invective aimed at physicians who advocated for gun control, to the tune of the following:
"Someone should tell self-important antigun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves."
The focus of their polemic was a position paper from the American College of Physicians that outlined a public health approach to reducing deaths and injuries from firearms. The backlash from physicians declaring this issue to be in their lane was fast and furious and included disturbing images from emergency rooms of blood-smeared surgical scrubs and floors and even the chair where one surgeon sits to tell parents their children have died of gunshot wounds. These are the consequences of gun violence that health care workers see.
Since then, as deaths from gun violence have continued to climb, I've spent a lot of time considering my own lanes. Where is the guardrail at which my responsibilities as a doctor end and my personal beliefs begin? What issues should I feel obligated to "own" as an upstanding and responsible member of my community – my hematology/oncology community, my hospital community, my parenting community, and my Cleveland community?
These are the lanes of my health care highway – some of the issues for which I feel I have a professional, moral, and ethical obligation to have an opinion. To be clear, these lanes are ones I have defined as my own, and not necessarily those of the American Society of Hematology or my hospital.
Gun Control/Gun Violence
Hours after the NRA posted its tweet, a man shot and killed 12 people at a bar in Thousand Oaks, California. In August 2019, 22 people were killed and 26 injured in a shooting in El Paso, Texas, and 10 were killed and 27 injured the following day in a shooting in Dayton, in my home state of Ohio. In October 2017, 58 people were killed and more than 400 injured in Las Vegas, Nevada. These are mass shootings – commonly defined as four or more people shot in one incident – and their victims total more than 1,000 people yearly in the U.S. Cleveland experiences more than 100 murders yearly, most of them shootings. We are up to 106 as of November 5 of this calendar year.
The sheer carnage, the randomness of the settings and people injured or killed, the horror of the violence, take my breath away, as they would anyone with a soul. While friends, family members, and patients of mine do own guns, and I personally don't oppose gun ownership (though I won't allow even toy guns in my own home), why anyone has a right to possess firearms that could cause this kind of butchery escapes me. The impact of these injuries and murders on health makes this my lane as someone who has dedicated his career to trying to preserve life.
That news of the killings in August 2019 kept my 10-year-old up at night for the week before he started fifth grade, fearful for his own safety when he returned to school, makes this my lane as a parent.
At the risk of oversimplifying why this is my lane as a hematologist/oncologist, when people are shot, they bleed. When people bleed, they need blood product transfusions. When people need transfusions, they deplete stored blood supplies. When people injured in the Las Vegas mass shooting needed blood product transfusions, we ran out of stored blood products in Cleveland, and my leukemia patients couldn't receive the blood and platelets they needed for two days.
Ergo, my patients, my lane.
Treatment of Immigrants
Reports of the conditions at U.S. Customs and Border Protection detention facilities have been appalling. Partly as a result of massive overcrowding, detainees may go days or weeks without showering, sleep on the floor when there aren't enough beds to go around, and receive inadequate medical and mental health care. A report from the Office of Inspector General of the Department of Homeland Security concluded that conditions were "unsafe and unhealthy" at the facilities they visited. A class-action lawsuit filed by immigration advocates against the Trump administration alleges that these conditions have led to permanent harm and 24 deaths in the past two years. Recently, it was announced that migrants in detention centers would not receive flu vaccinations, which one editorial decried "isn't just cruel, it's dangerous."
No doubt about it, these people, many of whom are escaping conditions so horrible in their native lands that they are willing to risk their own health and safety and that of their families to immigrate to a strange country, are now being placed at even further health risk. As before, this makes it my lane as someone whose job it is to preserve health.
As we reported recently, a study in Blood of refugees arriving to the Mediterranean coast of Italy and southern Europe found that they were not being screened for hemoglobinopathies, including sickle cell disease, and that the majority of diagnoses were made only after an affected individual presented to an emergency department. It's hard to deny this falling squarely into a hematologist's lane.
In the U.S., a complaint filed by the American Immigration Council challenged the inadequate medical and mental health care at an immigration detention center in Colorado, including failure to vaccinate people appropriately. If general medical care is deemed delayed or inadequate, we can guess that screening for or identification of cancer will similarly be foregone or delayed. In a review of Immigration and Customs Enforcement (ICE) detention standards to ensure that detainees have access to "appropriate and necessary medical, dental, and mental health care," there is no mention of vaccination strategies, nor cancer screening approaches. A study of vaccination strategies in Europe for recently arrived migrants found similar inconsistency. As we know, vaccines prevent life-threatening infections, including those (such as human papillomavirus) that can cause cancer.
Ergo, as a hematologist/oncologist, my patients, my lane.
Intolerance Based on Appearance, Ethnic Background, Gender Expression, or Sexual Orientation
Is it my imagination, or has America become an angrier place since January 20, 2017, at around noon? Gone are some of the societal niceties and acceptance that I had come to take for granted in our great land, replaced with venomous attacks against people of all backgrounds, even U.S. House of Representative congresswomen – attacks that were formally rebuked and deemed "racist comments that have legitimized fear and hatred of new Americans and people of color." Executive Order 13769 banned travel to the U.S. by people from predominantly Muslim countries and has been complemented by the frequent refrain of "Go back where you came from." Recently, the Executive branch told the Supreme Court that federal law allows firing workers solely for being transgender, and, in an amicus brief, asked the Court to lift federal prohibitions on antigay discrimination in the workplace.
Unfortunately, the anger and hatred go deeper than the chest-beating of public officials. As a cisgender, heterosexual ally white male, I become reluctantly privy to the conspiratorial slights, the barbs, the stereotypes, the slander, the racism, the homophobia, the intolerance voiced against these groups by other hetero-expressing white people – not often, but often enough.
It didn't used to be this way. But when high-profile public officials feel free to attack others at will, what's to hold an average member of the population back in casual discourse – even when I disagree and express my discomfort with the way the conversation is heading?
Intolerance and openly expressed anger erode trust in the people against whom the venom is aimed. And that erosion of trust can spread to include those who resemble the haters and to those in positions of authority. That means us: As doctors and nurses, we are respected members of our communities, and most of us don't fall into one of the groups targeted by those outbursts or policies.
If our patients don't trust us, they may not reveal all aspects of their medical or social histories to us. They may not seek medical attention from us at all when they are hurting. Both reactions – both understandable – can have a negative impact on their care and can delay diagnoses of blood disorders or cancers. It could delay those diagnoses enough that a condition that might have been remediable or curable becomes hopeless.
Ergo, my patients, my lane.