Medical Examiner

Patients Are Not Suspects

As a doctor who has also worked in the prison system, I’ve seen firsthand how much the language we use to describe sick people matters.

A woman lying on a hospital bed behind bars and wearing a face mask
Photo illustration by Slate. Photo by Amorn Suriyan/iStock/Getty Images Plus.

The Person Under Investigation sat on a stretcher in the emergency room, and was drinking a juice box. The coarse blanket draped over him and tangled electrocardiogram leads on his chest, a smudge on the floor, the Person’s dark eyes—all were illuminated under fluorescent lighting. His cellphone was running out of battery power, which worried him. He wanted to call his kids. He also left the dog in the house five hours ago. He wanted me to know this about the dog. Perhaps I could hurry up my evaluation?

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It was a Saturday. The display over the doctors’ station showed the department in a snapshot, a line for each bed. Last name, symptoms, pending tests. The pandemic had added a new acronym to the screen: PUI, short for Person Under Investigation. A PUI is someone who might have COVID. If the suspicion that the PUI might have COVID is especially strong, they can be called a “COVID suspect” or a “high-risk” PUI. A swab will clarify matters. While the test is pending, there is reasonable doubt. Hence, the investigation into the case.

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The PUI in front of me wanted me to know that none of this was his fault, that he did everything correctly—but sometimes things just happen, right? Nonetheless, here he was: a PUI.

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This is the language of the coronavirus at the ER where I work, and at hospitals and health departments across the country: PUIs. Suspects. Cases. You’ve heard it in your own life, too: isolation. Lockdown. The vocabulary we use for people who have contracted the virus—or even might have contracted it—shares so much with the vocabulary we use for incarceration.

As an emergency room doctor and HIV specialist, I’ve seen what happens when crime and disease are conflated. Just as an arrest record—even without conviction—elicits judgment, as does being “under investigation” or a “suspect” for potentially having a viral illness. It’s more than just language, though: Having certain viruses can make someone inherently more dangerous in the eyes of the law. I’ve treated people with HIV who were jailed for having sex that was unprotected—but fully consensual. I’ve studied the verdict in Commonwealth v. Walker, a 2003 case in which an HIV-positive man was convicted for terroristic threats after scratching a police officer and then implying the scratch would infect him. It didn’t matter that HIV can’t be transmitted that way; the mere existence of the virus in his body helped make him guilty.

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During my medical residency, I worked at San Quentin, a sprawling prison near San Francisco where the human cages of the main cellblocks tower many tiers high. On my first day, my supervisor told me that I was not allowed to refer to those I treated as patients in clinical documents—only as inmates. However much they suffered from illness, the language implied, it was essential never to forget their criminality. Learning to refer to my patients only by a word that dehumanized them took practice. For weeks, I messed up in my notes, and was made to correct each instance.

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After the start of the coronavirus pandemic, I didn’t have to wait long to see people punished for being sick with the novel virus. In one case, a father in Illinois who was supposed to self-isolate for symptoms was charged with a misdemeanor when he brought his 4-year-old into a gas station so the child could pee. In another case, a homeless man in Nashville fled a temporary isolation shelter for people with the coronavirus and was jailed for a week until his bail could be paid. Punishing him, it seems, took precedence over protecting other people in the jail from exposure to the virus.

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One weekend at my own hospital, a patient came to the emergency room, hacking in the waiting room and snapping at offers of a mask. He’d flown from Atlanta with a carry-on and a secret: the knowledge that his coronavirus test was already positive. Nothing could entice him to forfeit his return ticket. I burned with quiet rage.

“There’s not much we can do,” said the person at the Centers for Disease Control and Prevention when I called. She said she would try to block him at the airport.

“Can’t you arrest him?” I blurted out, before considering the implications: that however reprehensible his behavior, he had come to get care. Not to be seen by a doctor who acted like a jailer.

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The two professions have long interacted. Hospitals and prisons resemble each other, an observation articulated by the French philosopher Michel Foucault in Discipline and Punish. Having spent time as a physician in both types of institutions, I’ve seen the similarities. Nurses stations are like guard towers. Vitals checks are like roll calls. Restraints for the delirious are like shackles for the disobedient. Wards, of rooms or cells. Case files, of patients or criminals. A patient who leaves the hospital without permission is said to have “absconded.”

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And just as the prison system disproportionately affects people of color, so has COVID. It’s no surprise that the Person Under Investigation who sat in the emergency room drinking juice that Saturday was Latino. During the early months of the pandemic in San Francisco, where I live, the coronavirus swept through the Latino community. Nationwide, it has killed Latino, Black, and Native Americans at more than double the rate of white Americans, per CDC data. So many people of color are, after all, “essential workers” who often ventured out to the riskiest jobs, returned to homes crammed with multiple generations, had worse access to testing and treatment—and became all the more likely to wind up PUIs because of it. The language of COVID reinforces the racialized criminalization that already characterizes the United States, where Latinos are imprisoned at three times the rate of white people and Black people at 5.6 times that rate, according to a 2021 publication by the Pew Research Center.

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I can’t help but think it’s no coincidence that San Quentin, where I was told years ago to say “inmate” and not “patient,” suffered a massive coronavirus outbreak in 2020. Nationally, people who are incarcerated have died in huge numbers during the pandemic, with COVID mortality rates in federal prisons 2.6 times greater than those of the general population. The spread at San Quentin last summer, where two-thirds of prisoners were infected, was even more staggering than in most places. As documented in a report from the Office of the Inspector General of California, the cause was negligent and haphazard administrative practices by prison officials, including cramming inmates—some with symptoms—onto buses together, and then housing them in cellblocks where air circulated freely between cells. But maybe at the root of that, I imagine,  was a failure to treat those within the walls as people in need of as much attention and care as those outside. Guy Vandenberg, a nurse and former colleague who worked there during the outbreak with the job title of “Investigator,” told me that every day his team visited scores of prisoners exposed to or infected with the coronavirus. He recalled that, despite the protestations of health care workers, incarcerated people were not appropriately transferred to reduce the spread of disease, and many of the sick did not have access to what he considered adequate medical treatment. His morning rounds, he said, felt like an exercise in surveillance rather than care.

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Outside of the pandemic, the vocabulary of medicine has evolved dramatically over recent years to become less accusatory and to avoid equating a diagnosis with a person’s entire being. Heroin addict has been replaced by person with an opioid use disorder; wheelchair-bound by wheelchair user; patients are not illegal, but undocumented. We recognize people’s autonomy more. We ask people their preferred pronouns in the hospitals where I work. We no longer label people who choose not to accept our treatment recommendations as noncompliant.

A change in language alone might not have lessened my fury at the patient with COVID headed to the airport. But it might have checked my shameful impulse to jail him. It might also help us see the pandemic as a collective problem, not a battle between upstanding vaccinated mask wearers and ignorant scofflaws, a conceptualization that does nothing to solve the challenges we face. The mishandling of the pandemic is a crime, for sure—but one committed not by individual patients but rather by larger actors: the Trump administration, in its mismanagement and dissemination of misinformation, for instance, or the leadership of prisons in their handling of outbreaks.

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At the hospital, we could remove some of the blame from individuals by tossing the phrase COVID suspect. We could ditch Person Under Investigation too, and replace it with something as simple as patient with a pending coronavirus test. Not catchy, I’ll admit, but it conveys what it needs to. As for lockdown, it has come to describe such a spectrum of policies that the word has lost all meaning.

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I don’t know what the exact terms should be. They aren’t for me to decide. But I do know that as the delta variant has surged, the emergency room where I work, like many, has started to see more PUIs again. They panic from air hunger. They call their families, trying to sound calm. They wait for the results of COVID swabs that, in the language of the coronavirus, can feel more like verdicts than like diagnoses.

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Some of the sick have made decisions they regret: forgoing the vaccine or attending a wedding without a mask. But even if I struggle at times with anger over the choices people have made, I do know these are mistakes, not crimes—and that while investigation is warranted, it should be into how the forces and divisions in our nation have enabled the pandemic to kill hundreds of thousands of people, how we can turn things around now, how we can rebuild our health care system after the stress of this pandemic, and how we can better prepare for the next one. As for those who lie on stretchers across the country, coughing and terrified, they are in no way criminals for having a virus.

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