Here is part two of our analysis of SB1391 from a medical worker deeply acquainted with people with addiction and in recovery. This piece further articulates the relationship between medicalization and the history of anti-drug legislation, and lays out a series of mandates/demands for healthcare and society.
Another Care is Possible: Thinking Beyond Criminalizing Substance Using Mothers
Kristen was 19 when she took her first Percocet at a party, and for that moment, all of her depression and anxieties disappeared. But it also set off a decade of addiction to pills and eventually intravenous heroin. She dropped out of college and plunged from one crisis to another. It wasn’t until Kristen realized she was pregnant that she finally reached out for help and enrolled into treatment at a New York City public hospital where doctors provided her with treatment and helped her deliver a healthy baby boy.
Kristen’s story is not a miracle – recent findings have demonstrated the effectiveness of treatment for mothers with illicit substance and alcohol dependence. However the recent passage of Tennessee’s SB 1391 has dealt a blow to women’s rights and the autonomy of healthcare workers to provide quality care. The law mandates healthcare workers to report substance abusing mothers to the police, who face misdemeanor charges if babies are deemed to be harmed by the mother’s substance abuse. Despite evidence demonstrating the effectiveness of substance treatment, cuts in education, public housing, and healthcare services have crippled efforts to support women in recovery and diverted public funds to incarceration.
Such events are not incidental and are linked to dominant historical, ideological, and economic forces that shape how healthcare is provided. We must beyond such events and rethink our autonomy as healthcare workers and how we can collaborate with marginalized communities to launch more lasting alternatives. We must open spaces in and outside the clinic that can launch conversations that allow us to listen and collaborate with marginalized communities in order to launch new modes of reproducing care.
Nixon, Reagan, and ‘Just say no’
In the 1960’s, organizations such as the American Indian Movement, Black Panther Party, Young Lords, and Brown Berets rattled the core of the American establishment. In the wake of the Civil Rights Act and weakening Jim Crow era laws, Nixon’s ‘War on Drugs’ re–escalated the government’s disciplinary apparatus in communities of color. Spaces and social bonds that could produce non–capitalist alternatives were nearly annihilated, including radical organizations, unions, and eventually family and neighborhood networks with the waves of foreclosures, gentrification, and rising incarceration (particularly in communities of color). A new mode of economic production would come to dominate poor communities – the sale and consumption of illicit drugs.
Reagan’s assault on social services in the wake of rising unemployment and aggressive enforcement approach destroyed the lives of millions of Americans. The state abandoned the unemployed, the mentally ill, and those suffering from addiction – and were diverted to the care of families, non-profits, prisons, and even homelessness. America was transformed, from the state with a market, to a market state. The poor were now forced to participate in a new ‘market state’ of life in the tragic form of the drug trade. The sale of illicit drugs monetized personal relations and converted urban spaces that were once rallying points for radical organizations into the sale and consumption of drugs, with the state obsessed on an endless spiral of greater surveillance and incarceration.
Mothers in Care, Not in Handcuffs
In this context, the state has all but abandoned poor and substance using pregnant mothers to the mercy of hostile district attorneys and prison wardens. Many trends observed among pregnant mothers of color are parallel to national trends as well: 1) most mothers tested and incarcerated for substance use are women of color even though most addicted mothers are white; 2) substance treatment for pregnant mothers are tragically inadequate despite the promising outcomes of specialized clinics for substance using mothers ; 3) when forced into prison in order ‘to protect the health of the fetus’, substance treatment is nonexistent further hurting the health of the mother and baby; and 4) nearly half of detained mothers were tested positive for a physician prescribed substance (i.e. Percocet, valium, etc).
The mother has no voice in the clinic, courtroom, or her community – she is decontextualized from the dominant economic and political forces, vilified by the media, state, and scientific community, and left vulnerable to recurring witch hunts. For instance although Black mothers made up a fraction of the national crack epidemic, they became the replayed media image of a reckless wave of mothers poisoning a new generation of ‘crack babies’. Medical journals caught on and more often published data exposing the alarming impact of crack/cocaine on fetuses. This spectacle resulted in a moralistic subjugation, reducing the woman’s role in society to an organ (i.e. uterus) responsible for delivering a healthy fetus, whose legal rights superseded the mother’s. On the pretext of ‘saving the fetus’, many states have favored aggressive sentencing and incarceration of mothers rather than securing more equitable access to housing and healthcare.
Where Should We Stand?
To reflect on our autonomy, we must explore our relation to our institutions (clinics, hospitals); and our relation to the state, communities served, and existing economic and political forces.
This process requires that we have the space, time, and resources to define our relations based on social justice and scientific evidence rather than profit, power, and popular sentiment. To abandon our autonomy, our desire to care, and relapse into a disciplinary function. The disciplinary function leads to two tragic consequences for the mother, the obvious being that she is left in handcuffs rather than any form of care, and the more implicit and equally tragic is that we censor her from using a presenting illness as a point of departure to collectively respond to her concrete experiences. The mother is lying alone in the exam room, her ´complaints´, physical exam, and laboratory results are organized in a linear series of codes that neutralizes her from any desire to articulate a more concrete response to the broader socio-economic context with other mothers and allies. This process is done within minutes, and we are off to ‘manage’ the next case. To engage in this process ‘productively’, we internalize these contradictions, remaining complicit with the existing disciplinary forces (police, hospital administration), and feeling more bitter than ever.
The close proximity of our complicity in this process raises another question – how have we reached the point in our profession, education, and ethical framework to be placed in such close proximity with the police? Does such an intimate complicity and abandonment of our role as care workers call for a more intensive self-examination of a perhaps more discrete disciplinary function we fulfill in society? Similar to calls by psychologists to expel colleagues from professional societies that participate in state organized torture, can we draw a similar argument here? More importantly, can we organize our clinical practice, the layout and organizational flow of the clinic, to better care for mothers, and collaborate with collectives of mothers.
A Clinic Without Organs
After recuperating our autonomy, we offer several suggestions for collectively affirming our role in expressing the alternative.
1. We must cease to be the paternalistic intermediaries of the state when working with pregnant mothers or any other vulnerable populations. We should open spaces in the clinic and beyond that nurture bonds based on mutual aid, reciprocity, and collaborations with collectivized patients in order to launch new alternatives. The desire to collectivize with patients will require an exhausting, at times challenging, process of confronting our own paradoxical position of privilege within the hospital (and society) that has been instilled in our education, profession, and even union practices. But is nonetheless an absolute necessity in the struggle to deconstruct power and recuperate care and autonomous forms of socialization.
2. We must identify spaces and mechanisms that can allow us to sustain our collective expression, be it in the form of assemblies, committees, or radical organizations. This is perhaps the most challenging but necessary responsibility in protecting our historical significance
3. In the realm of public health, the legitimacy of those who claim to represent or speak for us (such as unions, politicians, academics, and media) repeatedly comes under question. Its not a matter of blaming – but a matter of unleashing our potentials. We must move beyond opposing positions that simply react and expire after a certain point. Our opposition should be directed to institutions and hierarchies that when effectively challenged, finally create an open space that unleashes our desires, collaborations, and alternatives. We must make our voices heard:
1) We will not report substance using mothers to the authorities. Platforms may include petitions, public letters to the media, and protests
2) Academic societies, healthcare workers, and organizations of pregnant mothers must inform healthcare workers that notify the police how they´re complicit with a broader trend of economic and political oppression, and explore other alternatives to help pregnant mothers. This process allows us to move beyond becoming fixed on a single legislation or co–worker, and to take collective responsibility for launch new subjectivities
3) In collaboration with marginalized pregnant mothers, we must expand research and implementation of specialized clinics that address the gambit of medical, substance, and social needs. Lack of access to primary care treatment drives patients back to ER’s and criminal justice settings, further perpetuating cynicism and disempowerment (of mothers and healthcare workers)
4) And beyond these few immediate demands and efforts, we refuse to prescribe any further alternatives until we´re able to collaborate non– hierarchically with mothers, in spaces that are open and able to sustain a longer–term conversation.
4. We must not shun ourselves from injustices perpetuated in the communities we serve, including unemployment, gentrification, racism, and other catastrophic events. We must have protected time from our places of labor to engage with community organizations in order to participate in efforts that respond to ‘upstream’ structural inequalities that result in worsening health outcomes seen in our facilities. In other words, every effort must be made to expand education, prevention, and treatment practices to prevent mothers from further worsening health outcomes requiring clinical intervention. These spaces will allow us to nurture new political subjectivities that move from the antagonistic, to the affirmative.
5. We must reclaim and transform existing healthcare infrastructure, technologies, and resources in a mode that allows our new political subjectivity to address local contextual experiences.
Tennessee’s legislation is more than a mistake, requiring an antagonistic approach confined to a profession, time period (i.e. the outcry and the win of removing this legislation), and self-assuring sentiments that the present is working, and capable of self-resolving future mistakes. Rather, such events must serve as a rupture to produce a period of interruption in which the law, complicit institutions, power dynamics, and ideologies are recognized, deconstructed, and materializing collectively affirmative forms of alternative building. We, the healthcare workers of the world, are drowned in concrete experiences, too much, to the point of becoming disillusioned, depressed, internalizing the cries of the oppressed, and we too, becoming oppressed in our cocoons – the unions don’t hear us, the state doesn’t hear us, but our patients do, our colleagues do – grab a concrete experience, embrace the rupture, collectivize, and articulate the alternative.