Abolition medicine
Authors: Yoshiko Iwai, Zahra H Khan, Sayantani DasGupta
Journal: The Lancet (2020)

Who do you serve, who do you protect? Doctors and nurses are not soldiers. Antibiotics are not bombs, hospitals are not the front lines, hard-working medical trainees are not "gunners", and neither disease nor patients are "the enemy". Militarised language valorises aggression and violence in medical training and the clinical encounter while obfuscating the loyalties of health workers who serve and protect individuals and communities in need. Narrative medicine, and the broader health humanities, is committed to honouring the stories shared between providers and patients, as well as understanding the structural narratives that contextualise experiences of health and illness. Narrative medicine teaches us that stories matter, particularly at moments of crisis, trauma, and upheaval. Language affects the way that policies, actions, and attitudes are shaped towards justice or injustice. Who tells a story? Who benefits from that story? Whose voice is heard and whose silenced? Who is framed as heroic and who villainous? All of these questions drive socially just narrative work. The dangers of military metaphors in medicine were most famously described by Susan Sontag in her 1978 treatise, Illness as Metaphor, but they continue to dominate professional and lay imaginings of health care. Doctors and nurses are not soldiers, and yet, in the late spring of 2020, even as US deaths from COVID-19 rocketed, the US military conducted flyovers above multiple cities to honour what were dubbed America's health-care heroes. These expensive gestures occurred while the federal government did not supply health workers with adequate personal protective equipment (PPE). Even as the country gathered nightly to clap for health-care heroes, lives were lost on the "front lines" and among the marginalised communities more profoundly impacted by COVID-19. Then, in early summer, uprisings erupted across the USA in response to a different public health crisis, that of structural and institutional racism. As health workers took to the streets to support their communities, some parts of the state moved from lionising its health personnel to injuring or arresting them along with other protesters, and even destroying their medical tents. Police SWAT teams swooped down on many US cities and the difference between real and metaphorical soldiers became startlingly clear: the militarised police and National Guard resembled an army, while health workers were stuck with persisting shortages of PPE and, in our view, a meaningless metaphor of heroism. Who do you serve, who do you protect? This question, taken from the title of a 2016 volume on police brutality and visions for community safety, is one that demands answering by health professionals more urgently now than ever. Not only who do health personnel, as individuals, serve and protect, but who do our hospitals, clinics, universities, and other institutions serve and protect? And, more importantly, who should we serve and protect? The gaping health disparities exposed by COVID-19 are consequences of a long history of structural racism that underpins the US health-care system. US history is rife with examples of medical experimentation on Black communities: from James Marion Sims' development of the pelvic speculum through unanaesthetised operations on enslaved Black women in the 1840s to the infamous Tuskegee Study of syphilis in the mid-20th century. The notion that Black patients feel less pain than their white counterparts can be traced back to histories of enslavement, as can, in part, the US epidemic of Black maternal mortality. If health workers wish to advance an equitable system of public health, we must reckon with medicine's racist past and how it shapes the conditions of a racist present. When, in 2014, doctors and trainees across the US held die-ins in solidarity with an earlier wave of Black Lives Matter protests, it was an act of speculation; it was narrative in action. Viral images showed white-coated bodies lying still, stethoscopes in hand. These photographs asked us to imagine what it would mean if these professional bodies were regularly targeted by police violence, asserting that racism was a public health emergency. In another widespread image from the White Coats for Black Lives (WC4BL) movement, Black male medical students wore hoodies under their lab coats, reminding viewers that some doctors' bodies are always more vulnerable to racist assault than others. Similarly, in 2018, after the publication of the American College of Physician's position paper on the country's epidemic of gun violence, the National Rifle Association tweeted that "anti-gun doctors" should "stay in their lane", which incited the #ThisIsMyLane movement by US physicians, another narrative-based action. Here, too, doctors relied on the spectacle of visual storytelling, posting images of their bloodied scrubs and shoes, and the exhaustion of their post-shift faces as they described the horrors of treating victims of gun violence. These physicians and physicians-in-training told painful stories and created arresting visual ones, not only to make clear who they serve and protect, but also to impact concrete changes in policy, legislation, and governmental funding. In 2020, many health workers kneel in solidarity with protesters and deliver care to those injured by rubber bullets, tear gas, and police violence as they call out the names of Breonna Taylor, Ahmaud Arbery, and George Floyd. In narrative medicine and the health humanities, we often turn to structural competency, a term coined by Jonathan Metzl and Helena Hansen, which suggests that medical trainees need to be taught to recognise upstream causes, such as food deserts and housing inequality, of downstream health consequences, such as heart disease and diabetes. What has become clear for us is that police violence is the upstream cause of this downstream pain, death, and disproportionate suffering. Police brutality is a public health emergency. As health workers, there is a need to imagine new possibilities for public safety that emerge from public health, as opposed to endangering it. New stories must be told about medicine, community, and care. There can be no apolitical humanitarian approach to police brutality. The violence that is, and has been, happening across the USA is being caused by an institution with concrete funding sources: the police. It is not an ethical or humanitarian act to patch up people who are being torn apart by guns without doing something about the availability of those guns. Similarly, it is not an ethical or humanitarian act to continue patching up communities who are being murdered by police brutality without doing something about the police state itself. What might a public health approach to public safety look like? At this time, this question is an act of radical imagination. But at one point in US history, the abolition of slavery, too, felt like the impossible. Both medical progress and racial justice are ultimately acts of speculation until they are actualised. By imagining, then working towards, new cures and technologies to address diseases, medicine itself is always committing acts of speculation. By imagining ourselves into a more racially just future invested in enriching communities, abolitionist physicians and nurses can work toward a future of health and social justice. Who do you serve, who do you protect? Past attempts at US police reform, whether body cameras or increased anti-bias training, have not been enough to prevent racist police brutality or the deaths caused by it. We believe it is time to serve and protect the communities we care for by working toward new systems of community care. Abolition medicine invokes W E B Du Bois's 1935 notion of "abolition democracy", a vision based not only on breaking systems down but also on building up a new, healthier, and more just society. Abolition has subsequently been championed by activist–scholars like Angela Davis and Mariame Kaba who have argued that the abolition of slavery was but one first step in an ongoing process of abolitionist practices to address racialised systems of policing, surveillance, and incarceration. Medicine can perhaps be added to this list. The essential work of abolition medicine is to interrogate the upstream structures that enable downstream violence, like police brutality, in addition to reimagining the work of medicine altogether as an anti-racist practice. Abolition medicine means challenging race-based diagnostic tools and treatment guidelines that reinforce antiquated and scientifically inaccurate notions of biological race. It means integrating longitudinal anti-racist training into medical education, including the history of racism in medicine and structural factors that produce racial health disparities, while actively recruiting, retaining, and supporting Black and other minoritised faculty, staff, and students. Supporting institutional efforts that provide reparations to communities of colour devastated by unethical medical experimentation, such as the class action lawsuit that ultimately awarded monetary restitution and a lifetime of free medical care to the families involved in the Tuskegee Study, is another instrument of social change for abolition medicine, as is advocating for universal health coverage. And these changes are only a beginning. Importantly for us, practising abolition medicine entails health workers joining national conversations about police abolition and using their social power to reinvest in programmes that build community capacity for mental health care, youth development, education, and employment, as well as harm reduction efforts around drug use, housing insecurity, and incarceration. Narrative medicine gives us the tools to see how militarised metaphors in health care obscure structural contexts by making unclear who we, in medicine, serve and protect. Health workers are not instruments of the state; our duty is to heal communities in need and critique those systems that allow minoritised communities to be disproportionately harmed, while rebuilding those systems in healthier ways. Abolition medicine is a practice of speculation, of dreaming of a more racially just future and acting to bring that vision to fruition. It is to recognise that the Hippocratic Oath to "first, do no harm" requires those working in health care to dream radically and act structurally. This is the possibility of abolition medicine: to renarrate and re-envision justice, healing, activism, and collectivity.