Organized Care as Antidote to Organized Violence: An Engaged Clinical Ethnography of the Los Angeles County Jail System.

The field of medical action extends beyond the clinical encounter. Rather, clinical encounters are organized by wider regimes of governance and expertise, and broader geographies of care, abandonment and violence. Clinical encounters in penal institutions condense and render visible the fundamental situatedness of all clinical care. This article considers the complexity of clinical action in carceral institutions and their wider geographies through an examination of the crisis of mental health care in jails, an issue of significant public concern in the United States and much of the world. We present findings from our engaged, collaborative clinical ethnography, which was informed by and seeking to inform already existing collective struggles. Revisiting the concept of "pragmatic solidarity" (Farmer in Partner to the poor: a Paul Farmer reader, University of California Press, Berkeley, 2010) in an era of "carceral humanitarianism" (Gilmore in Futures of Black Radicalism, Verso, New York, 2017, see also Kilgore in Repackaging mass incarceration, Counterpunch, June 6-8, http://www.counterpunch.org/2014/06/06/repackaging-mass-incarceration/ , 2014), we draw on theorists who consider prisons to be institutions of "organized violence" (Gilmore and Gilmore in: Heatherton and Camp (eds) Policing the planet: why the policing crisis led to Black lives matter, Verso, New York, 2016). We argue that clinicians may have an important role in joining struggles for "organized care" that can counter institutions of organized violence.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future.

OBJECTIVES: The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas. METHODS: A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult). RESULTS: A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout. CONCLUSIONS: Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Beyond border health: Infrastructural violence and the health of border abolition.

Most existing approaches to border health focus on identifying the social determinants that produce ill health and health disparities among migrants, including language barriers, documentation status, and trauma associated with migration. Attention to these kinds of problems can lead to policy and clinical changes that indeed help improve quantitatively measurable outcomes for patients. However, these approaches usually ignore the larger historical and political framework that determines the determinants - the underlying infrastructure of ill health, or what we term the infrastructural determinants of health. In this paper, we outline specific infrastructures involving race, political economy, history, and most importantly, borders themselves, that lay the foundations for border illness. We examine the plans, histories, policies, and peoples involved in building the conditions for migration, particularly out of the Northern Triangle, including forces of colonialism, US imperialism, neoliberalism, and border militarization. In place of a tacit acceptance of the modern system of borders, we argue for border abolition as a vital but underused treatment in the repertoire of medical intervention. Outlining the rights of people to stay and to move, and drawing on lessons from the prison abolition movement, we offer policies and practices towards a 'no borders' system that privileges liberatory solidarity with migrants by explicitly challenging global infrastructures that drive displacement. In doing so, we offer an emergent framework for a medical border abolition that treats both the causes and symptoms of a widespread global sickness.

Language Assistance for the Care of Limited English Proficiency (LEP) Patients in the Emergency Department: A Survey of Providers and Staff.

Many ED patients have limited English proficiency (LEP). Under Title VI of the 1964 Civil Rights Act, LEP patients are entitled to language assistance, however, multiple studies demonstrate that language assistance is underutilized. We aimed to characterize the knowledge, practice patterns, and preferences of ED providers and staff regarding language assistance for LEP patients. We performed a self-administered, anonymous questionnaire in an urban, public ED where most patients have LEP. Subjects included all ED providers and staff with substantial patient contact. We recorded ED role, knowledge of language assistance policy, prior training on working with interpreters, non-English language skills and bilingual certification. Outcomes included frequency of and comfort level with respondent's own non-English language (NEL) use in the ED, and the preferred and most frequently used modalities of language assistance. Of the 354 total ED employees, 261 were approached and 259 agreed to participate, which represents a 73% response rate (259/354). Respondents were 37% MD/NPs, 34% RNs and 29% other ED staff. Only 50/259 (19%) had prior training on working with interpreters. 171/257 (67%) were "unsure" if the hospital had a policy on language assistance. The most frequent modalities accessed for spoken language assistance were "Other ED staff" 106/259 (41%) or "ad hoc interpreter" 62/259 (24%). Although 227/274 (83%) use a non-English language with patients regularly, comfort levels in using their NEL for clinical care were variable. Most ED providers and staff had little training in the use of language assistance and were unaware of hospital policy. Use of NEL skills by providers for clinical care is common. Dissemination of best practices for the provision of language assistance and the clinical use of NEL skills has the potential to improve communication with LEP patients.

Undocumented Patients in the Emergency Department: Challenges and Opportunities.

In the United States, undocumented residents face unique barriers to healthcare access that render them disproportionately dependent on the emergency department (ED) for care. Consequently, ED providers are integral to the health of this vulnerable population. Yet special considerations, both clinical and social, generally fall outside the purview of the emergency medicine curriculum. This paper serves as a primer on caring for undocumented patients in the ED, includes a conceptual framework for immigration as a social determinant of health, reviews unique clinical considerations, and finally suggests a blueprint for immigration-informed emergency care.

Building Immigration-Informed, Cross-Sector Coalitions: Findings from the Los Angeles County Health Equity for Immigrants Summit.

In December 2017, the Los Angeles County Office of Immigrant Affairs and Board of Supervisors, alongside local health care and legal providers, convened the Health Equity for Immigrants and Families Summit to advance a vision for immigrant health. We describe the four critical concepts identified by stakeholders to address the varied needs of immigrants in an increasingly anti-immigrant political environment: (1) Recognizing immigration status as a modifiable social determinant of health; (2) Adopting the concept of "Immigration-Informed Care" within health care institutions; (3) Establishing immigration-focused medical-legal partnerships; and (4) Building coordinated systems based on knowledge of local stakeholders, policies, and funding mechanisms.

Barriers to the Right to Health Among Patients of a Public Emergency Department After Implementation of the Affordable Care Act.

Purpose: Emergency physicians are witnesses to the impact of socioeconomic determinants of health on physical and psychiatric illness. Understanding structural barriers to the right to health (RTH) serves as a foundation for interventions to promote health equity. This study was performed to determine self-described barriers to fulfillment of the RTH among a public emergency department (ED) patient population. Methods: A convenience sample survey between June and August 2014 of 200 patients in public ED assessing demographic characteristics and desired assistance with 36 barriers to fulfillment of the RTH. Results: There was a high demand for specialty care (91%, 182/200), access to primary care (87.5%, 175/200), and access to health insurance (86%, 172/200). Undocumented residents were significantly more likely to cite health insurance as the most important area for assistance (p=0.04). Conclusion: Despite implementation of Affordable Care Act, access to health care and insurance were still perceived as the most important barriers among underserved patient populations, particularly undocumented groups.

The right to water in rural Punjab: assessing equitable access to water in the context of the ongoing Punjab Rural Water Supply Proejct.

Although India is poised to meet its Millennium Development Goal for providing access to safe drinking water, there remains a worrying discrepancy in access between urban and rural areas. In 2006, 96% of the urban population versus 86% of the rural population obtained their drinking water from an improved water source. To increase access to potable water in rural areas, the World Bank and the state of Punjab have implemented the Punjab Rural Water Supply and Sanitation Project (PRWSS) to improve or construct water supply systems in 3,000 villages deemed to have inadequate access to clean drinking water. This study aimed to examine whether the right to water was fulfilled in six towns in rural Punjab during implementation of the PRWSS. The normative content of the right to water requires that water be of adequate quantity, safety, accessibility, affordability, and acceptability in terms of quality. While our findings suggest that the PRWSS improved water quality, they also indicate that access to water was limited due to affordability and the low socioeconomic status of some people living in the target communities.

Stage dependent aberrant regulation of cytokine-STAT signaling in murine systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a complex autoimmune disease of unknown etiology that involves multiple interacting cell types driven by numerous cytokines and autoimmune epitopes. Although the initiating events leading to SLE pathology are not understood, there is a growing realization that dysregulated cytokine action on immune cells plays an important role in promoting the inflammatory autoimmune state. We applied phospho-specific flow cytometry to characterize the extent to which regulation of cytokine signal transduction through the STAT family of transcription factors is disturbed during the progression of SLE. Using a panel of 10 cytokines thought to have causal roles in the disease, we measured signaling responses at the single-cell level in five immune cell types from the MRLlpr murine model. This generated a highly multiplexed view of how cytokine stimuli are processed by intracellular signaling networks in adaptive and innate immune cells during different stages of SLE pathogenesis. We report that robust changes in cytokine signal transduction occur during the progression of SLE in multiple immune cell subtypes including increased T cell responsiveness to IL-10 and ablation of Stat1 responses to IFNalpha, IFNgamma, IL-6, and IL-21, Stat3 responses to IL-6, Stat5 responses to IL-15, and Stat6 responses to IL-4. We found increased intracellular expression of Suppressor of Cytokine Signaling 1 protein correlated with negative regulation of Stat1 responses to inflammatory cytokines. The results provide evidence of negative feedback regulation opposing inflammatory cytokines that have self-sustaining activities and suggest a cytokine-driven oscillator circuit may drive the periodic disease activity observed in many SLE patients.