Emergency Departments Need To Claim Their Role In The Social Safety Net

A patient once told me, “I sit on the side of the road asking for change. People look right through me like I’m invisible. Food stamps aren’t enough. I can’t afford to exist and I want to die.” A man is dying of poverty — this is an emergency, but not one I have been trained to fix. I am an emergency medicine physician; I care for people on the worst days of their lives. I entered emergency medicine because I thought emergency rooms (ERs) were the great equalizer; emergencies happen to everyone. But that isn’t true. So many of our patients are experiencing what most of us would not consider a “medical emergency.” They go to the ER because they have nowhere else to go. And all I have to offer is a warm blanket and a turkey sandwich.

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Emergency rooms have been inundated by people struggling to breathe during this pandemic, but we will soon be seeing a new wave of emergencies: social and economic injuries. The economy has lost tens of millions of jobs. Homelessness is projected to increase by 40-45% this year due to the rise in unemployment and millions of people are newly experiencing food insecurity. COVID has laid bare vast inequity in our society and exposed the fragility of our social safety nets. Are we equipped for this “third wave?” Will ERs be able to help our country recover from this next national emergency or will they just exacerbate the disparities that have become painfully commonplace in America? To tackle this third wave will require a cultural shift in how ERs interact with their local environments.

The emergency room is where everyone can receive care regardless of race, gender, documentation status, or ability to pay. We are here 24 hours a day, 7 days a week, and all 365 days of the year. But emergency rooms are too disconnected from our communities to be effective in the coming challenge. When COVID was at its peak, local solutions to contain the spread were implemented: Homeless shelters closed and diverted to hotel rooms. Warming centers, food and clothing banks, and many other services that people experiencing homelessness rely on had newly limited hours and capacities. The landscape of resources fundamentally shifted, but physicians did not know to change their practice. They discharged patients from the ER, presuming they could quarantine, find shelter, get a ride to a drive-thru testing center, or had a reliable phone number to get their results.

Resources in the emergency room are strained and it has been a long year. It feels impossible to find the time to develop a discharge plan for a patient with so many socioeconomic obstacles, especially when there are dying patients in the rooms next door. Nonetheless, people come to us in good faith because we have made a promise to our communities: 24/7 and 365, whoever you are, whatever your emergency. In this tectonic moment, we cannot turn away from the structural needs threatening our patients.

Despite limited public funding for social and economic welfare, local resources do exist everywhere. Emergency rooms are situated, however unintentionally, as a catch point in the social safety net. We work in a sprawling network of municipal, faith-based, NGOs, and grassroots organizations, but our relationship to our neighbors leaves something to be desired. Many community organizations do not think to include the ER in their agendas or consider the ER as a place to implement programs because we have not historically opened our doors to them. It is time to shift that dynamic.

Local partnerships start with local people. Emergency rooms should hire community liaisons and organizers, people whose job is to know what is happening throughout a city and capitalize on the ER to expand outreach and link programs to patients. When drastic changes in the social safety net occur, like homeless shelters closing, there should be a pathway for informing ER providers on when and who to call for help. We are the axis of access but we need to know what we don’t know.

Whether by design or by accident, the ER stands at the forefront of this social and economic emergency, but we do not stand there alone. Mutually beneficial partnerships are necessary to build initiatives and pipelines to vital resources. Our patients, our communities, and our country, need economic resuscitation. They need more than a turkey sandwich and a bed in a hallway.

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