How the Poor (and Homeless) Die

Homeless encampment, Edinburgh cemetery

A powerful and classic (yet too little known) social justice writing by George Orwell is his autobiographical essay “How the Poor Die.” It should be required reading for all nursing and other health science students as it eloquently describes the experience of death and dying for poor and homeless people. Although the essay is based on his experiences, first as a poor patient on a public ward of a Paris hospital in 1929, and then back in England and Scotland (Glasgow) towards the end of WWII, there are echoes of truths in his observations that are relevant today. 

One of the most poignant parts of the essay describes “old numero 57” (patients were numbered, not named) lying—and dying—on a cot in the open ward next to Orwell. He writes, “They are treated like animals. They die alone, their organs already marked for a bottle in the museum, their bodies designated for dissection.” 

Orwell’s essay came back to me yesterday as I went in search of pauper’s grave sites in Edinburgh. From my research, it seems that there are thousands upon thousands of pauper’s graves in many of the town’s oldest remaining church cemeteries—such as St Cuthbert’s just below the Edinburgh Castle. They are buried in communal ( or, rather “mass”?) graves that are, of course, unmarked, and typically located in the now grassy central parts of the cemetery as shown in this photograph I took yesterday. There are older laws banning the grazing of sheep or cattle on these churchyard fields; current laws are posted banning all animals, including dogs (except for certified service animals). 

St Cuthbert churchyard

Edinburgh is infamous for its early to mid nineteenth century grave robbers, body snatchers, or “resurrection men” who dug up recently buried bodies of people and sold them to surgeons of the University of Edinburgh Medical School for their anatomy dissection. And then there were the body snatchers (and complicit surgeons) who took it even further, murdering poor and homeless men and women on the streets and in flophouses. People who died in poor/workhouses and public insane asylums and whose families did not claim (and pay for) their bodies were sold by the Overseers of the Poor to the medical schools for dissection. Is it any wonder that poor and homeless people have a well-founded fear of public hospitals and related institutions? 

A Call to Peace and Nursing

DSC00821Today, on this 100th anniversary of the armistice that ended the long bloody battle of World War I, I am reminded of the odd, and to me, unfortunate, relationship between war and nursing. Since I currently live in the land of Florence Nightingale, the lasting legacies of war nursing surround me.

From the Crimean War during Nightingale’s time, through the two World Wars, and on to the more recent wars in Afghanistan and Iraq, modern nursing developed alongside modern warfare. Of course, many medical advances have come from battlefield medicine. But nursing as an entire discipline (and only more recently a profession) in Britain came directly from wartime nursing practice. The legacies of this include a rigid, hierarchical, old-fashioned, and sexist nurse practice structure that is almost exclusively hospital based. The old-fashioned and sexist parts are how I view it, especially given the fact that British hospitals still have “ward sisters” and “hospital matrons.” And, nurse practitioners exist here in name only—they are not allowed to perform any of the expanded scope of nursing practice that we are able to do in the US. (Happy National Nurse Practitioners Week to all of you nurse practitioner colleagues back home. I have loved being a nurse practitioner now for a total of thirty-two years.)

How—and why—has American nursing developed in a different direction from that of British nursing? While I do not pretend to be an expert on the history of nursing, I imagine that the comparatively youthful cheekiness of early American nurse pioneers has something to do with our country’s diverging development of modern nursing. The American nurse pioneers like Dorothea Dix (mental health reformer/Superintendent of Women Nurses for the Union Army—if not a nurse herself she was certainly influential on nursing) and especially Lillian Wald, of Henry Street Settlement in New York City and founder of public/community health nursing.

Public/community health nursing does not and never has existed in Britain. Since public health/community health nursing and the expanded primary care role of nurse practitioner were what inspired me to even consider nursing in the first place—and are what continue to inspire me–I have come to realize that I would not be a nurse if I had been born in Britain or in any of the many countries which are former colonies of the British Empire (including Australia, New Zealand, and Canada.) Yet (and this is a big plus), the UK and these three countries/former British colonies all have some form of national health care. And, for the most part (Scotland where I am living is an exception), they all manage to have healthier populations overall for much less healthcare spending.

 

Note:

The photograph in this post is one I took in the Te Papa Museum, Wellington, New Zealand in 2016. It was part of an exhibition on WWI nursing and WWI’s effects on New Zealand in general. It was appalling to realize that entire populations of “fighting age” men (including Maori men) of New Zealand villages were killed in the war. WWI commemorative statues, along with the ubiquitous red poppies, abound throughout the tiny nation of New Zealand.

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A Cheeky American Nurse

P1020873Immersion experiences in another country, another culture, can bring out the best—and the worst—in people. While living abroad you cannot help but make moment-by-moment comparisons between where you find yourself and where you call home. Seemingly little things: if they drive on the left instead of the right as they do at home, which side of the sidewalk should you walk on? (Answer, at least here in the UK: there are no sidewalk etiquette rules. Expect complete chaos.) To deeper comparisons such as “Why are all British nurses forced into one of four possible specialties (Adult, Pediatrics, Mental Health, and Learning Disabilities) from the very beginning of their education?”  Is this Florence Nightingale’s legacy?

As a cheeky American nurse (and nurse educator) living and working in the UK, this British approach to nurse education is something I sincerely hope that American nursing never tries to adopt. There is much to admire about the UK healthcare system, with the prime example being the existence of the NHS—although imperfect, as are all healthcare systems, it is much loved and functions so much better than the US healthcare ‘system.’ It occurs to me as ironic that while the US healthcare system is more fractured than the British NHS, British nurse education is more fractured than is ours in the US. Or at least that is how it appears to me.

This British nursing forced specialization practice is a holdover from the days (not so long ago here) of hospital-based apprenticeship, diploma-level nursing. Of course, in the US, we have also had this form of nurse “training” that is fast being phased out. In the UK, there continue to be debates about the value of a higher education degree for nurses, with some people arguing that university degrees are responsible for the apparent diminishment of empathy among British nurses. Empathy cannot be taught, but it certainly can be encouraged and modeled. I do wonder: how well can that happen in any nurse education model based primarily on traditional lectures with a class size of upwards of 700 (or more) students and multiple cohort intakes and graduations each year? That is the current reality of nurse education in the UK. Mass marketing of (or attempts to teach) empathy not only do not work—they have the opposite effect.

Notes:

  • The photograph included with this blog post is one I took in London last month at the excellent Wellcome Collection Museum. Even if you cannot visit this museum in person, check out their website for amazing online resources, including their six-part series, “The History of the NHS.” 
  • Although I am currently situated at a UK School of Nursing, I first learned about the strange (to me) structure of British nursing from two non-fiction/memoir books: 1) The Language of Kindness: A Nurse’s Story, by Christie Watson (London: Chatto and Windus, 2018 and 2) One Pair of Feet, by Monica Dickens (yes, related to ‘that’ Dickens), (Middlesex: Penguin, 1946). Monica Dickens’ book is based on her brief stint as a hospital nurse apprentice during WWII. Christie Watson’s book is based on her twenty years’ work as a pediatric nurse in London hospitals. I highly recommend Watson’s book, but not the one by Dickens unless you are a WWII buff of some sort.

Goodbye Facebook, Hello (real) Books and Real Community

IMG_5410My relationship with Facebook and other forms of social media began eight years ago. I was a late adopter of social media and only got into it at the urging of various writing teachers and coaches. “Find your voice!” “Build your author platform and social media presence!” For the first years of my having a Facebook account, it was solely a a way to share my blog posts on this Medical Margins website. All fine, but then Facebook began to suck me in with its insidious tentacles of an addictive reward system: “Like my posts! Like my books! Like me, like me!” And the equally powerful addiction to the activating qualities of stress, reading posts (real or fake, who knows?) like “The world is on fire! Trump did this, said that! The sky is really falling you silly Chicken Little!” Suddenly, the people I was following most closely were beginning to add posts like “How much drinking is too much?” I knew it was time to step away from the screen.

I recently took a refreshing break from Facebook, having it coincide with a study abroad experience. One of the first things I noticed was a changed (and healthier, I might add) renewed relationship with the world around me. That gorgeous, unknown-to-me purple plant growing out of an ancient stone wall along the Water of Leith in Edinburgh? Ah yes! No need to quickly pull out my iPhone and snap a photo to add to Facebook or Instagram or Twitter or whatever. Stop and admire the plant and not feel the need to instantly share it with the world. (Although, yes, I will share it with you in this post.)

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What I told myself as I stood there contemplating this flower. Stop. Wait. Listen. Notice the people walking by on the river walk path. Notice the trees rustling in the wind. Notice the squawking ducks begging children for bits of bread. Notice the wee public library just up that cobblestoned street. Go into that library and see what’s on offer.

The newly converted, cleansed, on the wagon folks of any sort can be quite insufferable, so I will spare you the platitudes. I do recognize the positive uses of Facebook and social media—finding old friends in far-flung reaches of the world, checking on the ‘safe’ status of a friend in the eye of a hurricane, rejoicing in a friend’s success in whatever they find successful. Virtual communities can be powerful sources of information and support for people, especially for marginalized groups. But they are just that—virtual. When they take the place of actual face-to-face, in the local library or corner cafe community-based interactions, that is when skewed realities and misunderstandings and deep divisions flood in and take over our lives.

For now at least, I am officially off most all social media platforms. I have broken up with Facebook and you can find me either in the local library (where I am writing this and channeling my repeat visits to the Mother of All Libraries in the photograph above—the British Library) or at a community cafe.

 

No Time to Be Silent: On Radical Nursing

P1020860There is a time and place for silence, but only when it is freely chosen, not imposed. But now is not the time for silence. Now is the time to step us, speak out, and, at least in the United States, to vote. It is time to remember that progress on human rights and social justice issues in our world is not a given. That basic respect for girls and women is not a given. That universal abhorrence of gender-based violence is not a given. We all have to work for it—even when (and especially when)—our lives are turned upside down.

Nurses are the most trusted professionals in both the U.S. and the U.K. (although tellingly, nursing was only added as a legitimate profession to these polls in the U.K. two years ago). As nurses, we have always prided ourselves on being truthful, for speaking out and advocating for our individual patients or communities. But for various reasons (including a lack of contemporary role models or inclusion in nursing curricula), nurses have not be so good at political advocacy and activism.

Historically, nursing does have some amazing examples of nurses who bucked the status quo, spoke truth to power—who were radical nurses. Florence Nightingale in the U.K.—and especially her work after the Crimean War in bringing nurses to work in poor/workhouses in England.  And in the U.S., my favorite historical role model is Lillian Wald in New York City. Lillian Wald founded the Henry Street Settlement in the poorest section of New York City, and she founded public health nursing. Public, community, population health nursing is what drew me to nursing in the first place and it continues to be my passion. Public health nursing work is always political work.

In the U.K. in the 1980s there was the short-lived but influential Radical Nurses Group (RNG). Some of their archived material was the subject of a (again, short-lived) blog, “The Radical Nurses Archive” written by a former NHS nurse using the lovely pseudonym, The Grumbling Appendix (with another blog on nursing and politics in the U.K. that ended in 2015).  Where have the radical nurses in the U.K. gone? I am currently on a quest to find them.

Back in the U.S. we have the NurseManifest website and resources on nursing and activism co-founded by Sue Hagedorn, Peggy Chinn, and Richard Cowling. Beginning in the summer of 2018, they have added the Nursing Activism Project with a growing list of historical and contemporary nurse activists “Inspirations for Activism.”  In addition, they have a dynamic list of resources for nurse activism.

No excuses. All you nurses out there in the world: Get informed. Get inspired. Get active.

I include a recent interview I had with my colleague here at Edinburgh Napier University School of Nursing and Social Care, Dr. Peter Hillen, on nursing and activism.

 

Beyond Endurance

P1020950.jpgI believe her. I cannot imagine what sort of man-made hell (quite literally) she is now living through wherever she and her family are in hiding. I like to think of them as the trees pictured here are doing—embracing and supporting each other. From an ocean away, I can at least virtually support her.

I am, of course, referring to Dr. Christine Blasey Ford and her forced-to-go-public allegations of sexual assault as a 15-year-old at the hands (and body) of Trump-supported Supreme Court nominee, Brett Kavanaugh. Trump, and many male Republican senators, have publicly called Dr. Ford a liar. Would we expect anything different, anything better from men who excuse their own misogynistic beliefs and behaviors as mere locker-room boorish boy banter?

I do understand the long-lasting negative effects of surviving sexual assault. I understand the power of love, support, (good, woman-centric) therapy, time—and of telling one’s own story if and when one is ready to do so and when one is ready—in healing, in survival, in resilience, in endurance. In, as is used well in Indigenous Studies, survivance: survival/endurance or perhaps survival/resistance.

I wish for Dr. Ford and other brave girls and women in the world survivance and goddess-speed.

Reflections on the Poor Laws

P1020893.JPGWater of Leith, Edinburgh, bench beside Saint Bernard’s well with a statue of Hygieia, goddess of health

The largely impenetrable layers of history and how we humans are so prone to repeat past mistakes.

That is what occurs to me today as I walk these ancient paths and sit beside an ancient, pagan well of healing—mineral waters—overlaid, of course, by Christian (Saint Bernard) and ancient Greek (Hygieia) symbols. After a morning of reading ancient British Poor Laws—weeks of researching them and tracing their repercussions today, not only in the U.K. but also in the U.S. and in Seattle/Washington State. The worthy and unworthy poor. The deserving and underserving poor. The impotent poor. Paupers. Vagrants. Ruffians. Charity and its attendant ills. Solidarity and its limitations.

Beige mud puddles surround me here as I sit on this bench, barely staying dry underneath my umbrella. What sort of stone is all this beige-ness? (note: ancient sandstone, over 300 million years old.) The entire city of Edinburgh is composed of beige stone. And what minerals are in this water? (note: Sulphur, magnesium, and iron it seems.)

A soft purple Scottish thistle—late blooming ones in the midst of a large patch of blackened, dried up plants with thistle heads. There seems to be a prickly and a not so prickly version of thistles here. Why is the thistle the national flower of Scotland? (note: no one seems to know although there is a story about it that involves Norwegian invaders by sea who stepped on the thistles and alerted the Scots to their presence.)

Why aren’t nurses taught more about the history of social welfare and of the legacies of ancient pauper laws? Are they taught that at all here in Scotland or elsewhere in the U.K.? How much of it are even social workers taught either here in the U.K. or back home in the U.S.? It seems so important and puts many things in perspective, especially in terms of addressing the current thorny question, “What to do about the homeless?” And my own ongoing work in the vicinity of that question. I almost feel cheated in not having known about it much earlier in my life and my career as a nurse.

The deep layers of the histories of places and peoples are important to acknowledge, to know, at least at some more than superficial level. Is this something that can only be appreciated as one ages and takes on a proper sense of time?

A beechnut exploded, scattered on the ground along the river walk path wending its way beneath an old tree. They look like flowers but are hard. I try to press one between these pages and it breaks through the paper. Only the seeds remain.