Neha G. Reddy, MPH1, Sarah Nuss, BS1, and Sylvianne Shurman, BFA1
1 Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
Correspondence concerning this article and requests for reprints should be addressed to Neha G. Reddy (neha_g_reddy@brown.edu)
ABSTRACT
COVID-19 has raised many questions for the medical field as a whole about how to best deliver patient care during a time that has greatly exacerbated pre-existing disparities and structural inequities. As preclinical medical students volunteering at a free clinic as it expanded to become a COVID testing site, we have had unexpected opportunities to reflect on what it means to be medical students who do not yet have the requisite clinical training to medically care for patients during a pandemic. In the process of recognizing our own limitations and considering how to best support clinic staff and patients, we learned an immense amount from the mutual-aid frameworks of local organizers who act through solidarity rather than charity. Ultimately, we have come to reflect upon potential growth opportunities for medical schools to incorporate educational practices that support students in authentically and longitudinally integrating within our communities. These lessons on how to support the holistic healing of our neighbors will continue to inform our work long after COVID.
When we began medical school last fall, we were encouraged to reflect on what it means to join the medical profession, and how we could best embrace our new vocation on the path to becoming doctors. For medical students, there are always ethical challenges when considering our role in patient care and community engagement. We each want what is best for patients, but as students, there is an inherent learning curve that must come at some cost. During these last few months, that dichotomy has been thrown into sharp relief: how can we, as new medical students without clinical skills, be useful during a pandemic? How can we channel our drive to serve others into productive avenues while being mindful of unintended consequences? For the medical profession as a whole, this crisis has covered new territory, with each day bringing new challenges. How could we find our place amidst the chaos?
For many years now, our medical school has maintained a relationship with a free healthcare clinic serving primarily Spanish-speaking immigrant patients in Rhode Island. Much of the patient population is uninsured or under-insured, is unable to access federal aid and other governmental services, and faces significant challenges to accessing care. As board representatives for student involvement at the clinic, we were immediately concerned about the adverse impact of COVID-19 on the patient population and the likely strain it would place on the clinic staff. How would patients access testing without access to a primary care physician or if they were concerned about their legal status? How would families that share a one-bedroom apartment be able to quarantine a symptomatic family member? Would patients with tenuous health be able to continue to access their medical care? And while many undocumented individuals have the least amount of financial stability and social resources, how would they weather this challenge without government stimulus aid?
Soon after the pandemic began, the clinic became a testing site for COVID-19. The importance of the clinic’s work as a testing center for uninsured patients and as a free clinic that serves Spanish-speaking communities during this pandemic soon became evident. In Rhode Island, 44% of positive COVID-19 patients are Hispanic/Latinx, although they make up just 15.9% of the state's population [1,2]. While CDC data shows that, nationwide, a disproportionate number of people of color are affected by COVID-19, there is still substantial data needed to understand the magnitude of these racial disparities [3]. Immigrant communities work jobs in the service industry, construction, and factories that are the most likely to be hit by COVID -- leaving many families, some without documentation status, out of work and ineligible for government relief aid to support their families [4]. On top of these challenges, patients face language barriers and heightened fears of deportation during this time of uncertainty [5].
During the early weeks of the pandemic, we brainstormed a list of ways that we, as students, might be able to support the clinic. We offered our services as Spanish interpreters for telemedicine calls and translating online materials about COVID-19 for patients. We worked with the staff at the clinic to draft protocols and intake questionnaires to set up the clinic as a COVID-19 testing site and offered to help call these patients back with their test results. We even wanted to serve as case managers for patients in need of social services.
Yet, as the pandemic progressed, the environment around us evolved. The clinic’s providers, who were stretched thin in many other ways, were able to connect more efficiently for telehealth appointments without student translators. The Rhode Island Department of Health had ramped up efforts to perform contact tracing and was able to call patients before we even had access to test results. These positive developments still left many holes to fill, but it was difficult to find meaningful ways to support the clinic and combat the numerous challenges that staff members were facing.
And so, we were asked to reflect, what is our role as medical students during a health crisis? The AAMC guidelines suggest that medical student involvement during COVID should be limited in clinical settings. Yet, at the same time, many medical schools have expedited graduation to allow new graduates to assist on the frontlines. We recognized early on that as preclinical medical students, we did not have the requisite clinical training necessary for direct patient care; however, the idea of sitting idly by during a health crisis felt unacceptable. Whether consciously or not, many of us were driven to medical school due to our problem-solving nature. It was difficult to reconcile that while we were supposedly well on our path to becoming medical professionals, we are distinctly not there yet.
While we took a step back to reflect on our role at the clinic, we realized there were important lessons to learn from the discomfort we experienced. Most importantly, we saw community organizations all around us step up to meet the needs of their neighbors -- working tirelessly to scale up their services, fundraising, packaging and distributing goods, and connecting folks to resources. These actions of mutual-aid are founded on principles of solidarity rather than charity, and involve community members organizing to support one another to meet basic needs, operating with the understanding that systems of power are often not built to meet the needs of marginalized people [6,7]. Examples of mutual-aid during COVID-19 include free grocery delivery programs to the elderly and immunocompromised, child care collectives to support healthcare and essential workers, and prison bail funds [8]. We realized there was much we could learn from these mutual-aid volunteers, particularly in expanding our understanding of population health beyond the capitalist frameworks of organized medicine.
The skillsets employed by these advocates are often not prioritized in medical school: how to ethically engage with a community, how to truly listen to what someone wants for their wellbeing and trust individuals and communities to guide their own survival and healing. Many of us are not pushed to ingrain ourselves in our local communities beyond the set parameters of student clinics or annual service-learning experiences. So when a crisis like COVID hit, we were left unprepared to fight the damage wreaked on those we strive to serve. This is not to say that students cannot and do not do wonderful work, but this crisis has shown us that we may be ill-equipped to holistically support patients in times of heightened need. Furthermore, due to the transient and time-bound nature of community engagement during medical school, medical students are often, and with good reason, not seen as trusted members of the communities in which they reside.
Through listening and learning, we began to find ways to provide support as community members before medical students. During testing intake calls and primary care visits, more patients began to screen positive for food and financial insecurity than the clinic has previously seen. It quickly became clear that the capacity of the clinic staff to meet this need, amidst all of the other work they were suddenly tasked with handling, would be limited. We decided that the best way we could support the clinic was to help coordinate local food dissemination initiatives for families hit hardest by this pandemic. We have been able to capitalize on our privileged position as medical students and the resources we have available to us, such as access to cars, connections with food distribution centers, and our physical ability to transport boxes. We collaborated with community health workers to identify patients who could benefit from food resources. We recruited medical students to call patients and gather more information about their food needs and have been working with local food pantries and grocers to get food donations and purchase gift cards. We have a team of students who have been making no-contact deliveries to nearly 100 households thus far. This process is still evolving, and we are learning more every day, facing questions about the long-term sustainability of our efforts. But for now, it seems to be the best way we can support clinic staff and patients as the pandemic rages ahead.
COVID-19 has shined a light on the essential work of community-based free clinics, whose staff work tirelessly to provide care and extend services to uninsured families in the most trying of times, often with very limited external support or resources. We have and will continue to learn an immense amount from the mutual-aid frameworks of local organizers to inform ways of supporting the clinic that are longitudinal and driven by the expertise of community members. As newly minted medical students, this pandemic has ultimately been a lesson in recognizing the importance of humility and stepping back, rather than opting in, to appreciate ways we can be most helpful. This lesson will continue to ring true long after the worst of this pandemic has passed and will inform the ways we engage with and support the holistic healing of our communities.
REFERENCE
RI Department of Health COVID-19 Response Data Hub. RI Department of Health COVID-19 Response Data Hub, ri-department-of-health-covid-19-data-rihealth.hub.arcgis.com/.
U.S. Census Bureau QuickFacts: Rhode Island. Census Bureau QuickFacts, www.census.gov/quickfacts/fact/table/RI/RHI725218#RHI725218.
COVID-19 in Racial and Ethnic Minority Groups. Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 22 Apr. 2020, www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html.
Taladrid, Stephania. The Risks Undocumented Workers Are Facing During the COVID-19 Pandemic. The New Yorker, 13 Apr. 2020, www.newyorker.com/news/video-dept/the-risks-undocumented-workers-are-facing-during-the-covid-19-pandemic.
The Impact of COVID-19 in Undocumented and Immigrant Communities. Human Rights Communications Workers of America, Mar. 2020, cwa-union.org/sites/default/files/the_impact_of_covid-19_in_undocumented_and_immigrant_communities_.pdf.
Solidarity Not Charity: Mutual Aid & How to Organize in the Age of Coronavirus. Democracy Now!, 20 Mar. 2020, https://www.democracynow.org/2020/3/20/coronavirus_community_response_mutual_aid.
McMenamin, Lexi. What Is Mutual Aid, and How Can It Help With Coronavirus? VICE, 20 Mar. 2020, https://www.vice.com/en_us/article/y3mkjv/what-is-mutual-aid-and-how-can-it-help-with-coronavirus.
Tolentino, Jia. What Mutual Aid Can Do During a Pandemic. The New Yorker, 11 May 2020, https://www.newyorker.com/magazine/2020/05/18/what-mutual-aid-can-do-during-a-pandemic.