Don’t let vindictiveness creep into medicine like it has in politics

The callous and inhumane resettlement of migrants recently committed by the state governors of Florida and Texas reminded me of an equally despicable and appalling tactic employed by health care workers since the 1960s: “greyhound therapy.”

Greyhound Therapy refers to attempts by health care workers and administrators to remove unwanted patients from emergency rooms, hospitals, and other types of facilities by providing them with one-way tickets on a Greyhound Lines bus to some other remote location make available in the hope that they will never return. Some of the patients are troublemakers and rioters who are frequent visits to emergency rooms, but the majority are destitute, homeless, or mentally ill – or all three – and deserve our compassion.

Greyhound therapy is still at play in certain medical and psychiatric circles. Between 2013 and 2018, a Nevada state psychiatric hospital routinely bused patients to places they had never been or had no connection with, providing rations and medication for just a few days for the trip. A class action lawsuit was filed against the hospital on behalf of about 1,500 discharged patients, and a Las Vegas jury ruled unanimously in favor of the patients, awarding each person $250,000 for the hospital’s egregious treatment.

A more widespread, but no less derisive, practice is patient “dumping”—the dumping of uninsured and unwanted patients on the street or their transfer to another facility. Patient dumping was — and still is — such a big problem that it literally took an act of Congress to stop it: the federal anti-dumping law passed in 1986 known as the Emergency Medical Treatment and Active Labor Act (EMTALA).

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Patients on EMTALA must be medically evaluated and stabilized prior to discharge or transfer. If a hospital is unable to stabilize a patient due to its resources, or if the patient requests it, a transfer can be made with the consent of the receiving hospital.

Greyhound therapy, dumping and the breasting of migrant workers all have their roots in the Freedom Riders. Freedom Riders were civil rights activists who ran interstate buses in segregated Southern states in 1961 to challenge the Jim Crow Laws, which remained in effect despite Supreme Court decisions prohibiting racial segregation in schools and public buses and depots.

In order to embarrass liberals in the North and humiliate blacks, the White Citizens Councils in the South and other groups opposed the Freedom Riders. “Reverse Freedom Riders” gave blacks one-way tickets to northern cities with false promises of jobs, housing, and a better life. The Kennedy White House received mail from leaders in target states urging the federal government to intervene in the gruesome human trafficking of people of color.

The past behavior of the fanatics is remarkably similar to the current behavior of the governors of Florida and Texas. As one columnist noted, the two governors were simply following an old script by shipping the migrants north. The governors weren’t smart. They were racist. At least Arizona officials were coordinating their efforts to relocate migrants.

The vindictiveness recently displayed by governors cannot be attributed to implicit bias. Implicit bias arises from prejudices that unknowingly influence how people, especially minorities, are treated. However, there is nothing ignorant or unconscious in the minds of those who orchestrate and authorize the trafficking of vulnerable populations.

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Exploiting people’s misery for political ends is shameful and no more acceptable than sending patients down blind alleys. JFK called the Reverse Freedom Rides “a pretty cheap shot.” He envisioned government contractors treating their employees without regard to race, creed, color, or national origin. Shouldn’t that also apply to healthcare professionals?

The concept of equal medical treatment goes back to Hippocrates. He declared, “Whatever houses I go into, I will enter for the sake of the sick…whether they be free men or slaves.” In many medical schools in the United States, it has become common for prospective medical students to write their own version of the Hippocratic Write and recite oaths. Many of the variants contain language that specifically prohibits discrimination or bias in medical practice.

I’ve often marveled at the state of mind of healthcare providers who endorse one-way travel as a solution to homelessness, drug addiction and mental illness. Nevada health officials weaved a thin veil of excuses, ranging from denial to claims that they were sending patients directly to family members and other mental health facilities — potentially true in some cases, but dead wrong in most cases. There was evidently a blatant disregard for human rights fueled by prejudice and stigma towards the mentally ill.

Nevada is not alone in its brazen treatment of psychiatric patients — nor do Southern states have exclusive rights to export their citizens. New York City secretly sends homeless people to Hawaii and other states. Only in rare cases does travel therapy aim to be truly therapeutic.

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For example, Hawaii has attempted to reunite the homeless with relatives on the mainland, known as airplane therapy. But due to the high cost of running such a program and the fact that approximately one-third of Hawaii’s population is temporary or from out of state, the number of those in need who actually benefit is very small.

The American Medical Association is concerned about “scope creep” that threatens patient safety, that is, the introduction of progressive practice providers into medical practice. I’m more worried about the repercussions of harsh politics. Anyone – politicians, utilities, or health care administrators – who uses people as pawns for leverage or personal gain, or who supplants or interrupts their medical treatment for biased reasons, should be guided by serious self-reflection about how racism entered their lives and what else more importantly, impacted the lives of innocent people and disadvantaged patients.

Politics, whether in the Capitol or the hospital C-suite, should never take precedence over people. Leaders and caregivers must never forget the salutatory inscription engraved on the Statue of Liberty’s pedestal – “Give me your weary, your poor” – and most importantly the following words: “Send to me these, the homeless, storm dead.”

Like many of our patients, migrants are overwhelmed by the living conditions. We are, and always have been, a nation that opens its arms to vulnerable people, rather than sending them to a destination far worse than where their journey began.

Arthur Lazarus is a psychiatrist.

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