Keep, Drop, Modify—
Moving Beyond the Medical Model: Forget What’s Feasible

Elizabeth A. Samuels, MD, MPH, MHS
Assistant Professor of Emergency Medicine,
Brown Emergency Medicine,
Alpert Medical School of Brown University

︎Download PDF

While the COVID-19 crisis demanded increased restrictions, it also opened opportunities to rethink how our society approaches care delivery, social inequities and the social contract. Over the past year and a half, we have publicly reexamined how our society does and does not provide care—and exposed who  is most vulnerable.

We identified and changed policies that presented barriers to people’s health and safety. We recognized that loss of housing could be deadly, so we put a moratorium on evictions and provided rent relief to some. We recognized living in congregate shelters could place people at higher risk of COVID, so some were moved to alternative spaces. We expected people to stay in their homes (if they had them), so we expanded food delivery and access to healthcare through phone and video telehealth. Many were willing to look at old problems with fresh eyes and to prioritize people over “how things are done” and not just implement policies because they are feasible but because they are needed and morally right.

These measures eased the economic and personal injury of the pandemic to some degree. They also opened a window to allow us to identify fundamental issues with our current social contract. We need a society that values people as inherently worthwhile and prioritizes meeting people’s basic needs—a society where we could and would be humanists. However, policy changes during the pandemic have been limited and temporary. Eviction poses health risks all the time, not just during a pandemic, and yet the moratorium is expiring. Housing shouldn’t be temporary; it should be permanent and supportive. Low-barrier treatment options that are person-centered and responsive should always be available.

Opioid overdose was declared a public health emergency in 2017. Overdose deaths have risen during the pandemic—and are rising at a faster rate in communities of color. This indicates that we have not fundamentally changed anything about how we have approached substance use and people who use drugs. Anyone marginalized, criminalized and stigmatized before COVID continues to be marginalized, criminalized and stigmatized now, fueling ever-increasing overdose deaths.

Taking a lesson from COVID, we can and should make policy decisions not based on what is thought to be feasible, but what will protect and keep people safe, healthy and alive. The medical model has much to offer people who use drugs and those with substance use disorders, but it will not address the overdose crisis in and of itself.

We must move upstream and tackle the underlying causes of what has produced and continues to accelerate overdose deaths. On the surface, overdose prevention centers, drug decriminalization and low-barrier treatment may seem like radical ideas, but in reality they are policies centered on human decency and dignity that value the health and lives of people who use drugs and people with substance use disorders. We have shown that we can redefine what is feasible. We just need the political will to act.