Teaching Health Politics and Policy in the Time of a Pandemic

Where to begin? For one thing, I will begin by acknowledging that I still have a job, and I have a job that can be done from the “shelter in place” comfort of my own home here in Seattle. These are privileges that I am acutely aware that many others in my neighborhood, city, country, state, and world do not have. These are privileges that homeless people I work with do not have.

I will not complain about having to “pivot” (but oh how I loathe that over-used term right now!) and convert a new health politics/policy course from an in-person class format to completely online within a week’s time. I will not complain that the hastily-added Zoom feature on our course websites is already crashing and our spring quarter has not yet begun.

The course I designed and will be teaching starting next week is a required course for all pre-licensure nursing students in our newly revised curriculum that rolled out this past fall. I have a cohort of about 150 students, a mixture of traditional BSN students and accelerated BSN (ABSN) students–meaning they already have a degree and complete their nursing courses in one academic year. The ABSN students will soon graduate and enter the nursing workforce. Many of them, as well as the BSN students, are already working as nurse techs in hospitals and nursing homes. Since most of them live and work in the Seattle area—the site of our country’s first COVID-19 outbreak and known community spread and mounting death toll along with the insane shortage of basic protective gear like masks—they know first-hand two lessons included in my course syllabus: 1) US healthcare is characterized by excess and deprivation (rich people still getting tummy tucks and facelifts while COVID-19 patients die from lack hospital beds/staff/ventilators), and 2) rationing of healthcare is already a reality even before the COVID-19 pandemic reached the US.

Luckily, I had this same cohort of students last fall quarter in a community/population health course which we now lead with instead of including as an afterthought as most nursing schools still do. As part of that course, I had them complete the excellent (and free!) online training modules on disaster preparedness (include mental health/PTSD in first responders) from the Northwest Center for Public Health Practice. I also had them write a narrative policy paper based on Health Affair‘s “Narrative Matters” series of essays. Many of their papers were excellent and based on current event public health/health policy topics.

For the spring quarter health politics and policy course I will have them work in teams (virtually, of course) of ten students and write and produce 8-10 minute personal policy and advocacy storytelling videos based on current event topics (including the pandemic). These are based loosely on the StoryCenter/Nurstory series of videos, although all of theirs are single person-single story videos. (One of my favorites is “Pride and Prejudice” by Maud Low on reproductive rights.) I am excited to see what they come up with and will–with their permission–share/link to some of their final participatory/narrative policy videos at the end of the quarter.

In yet another surreal moment in the midst of numerous such moments during this time, I am struck with the fact that by writing/thinking about “the end of the quarter” I have the simultaneous realization that—assuming my students and I are still standing (or sitting, or lying) by then—we will all have been even more profoundly and personally touched by this pandemic.

What if? What now?

Life is surreal in Seattle in the midst of the COVID-19 epidemic, with our rapidly mounting fatalities from the disease and steady upticks in people testing positive (for the fortunate ones who even have access to testing). The bizarre and awkward dance of social distancing with people walking out into our near empty streets to avoid passing other people at too close a distance. Children riding their bikes in circles outside their houses while frazzled-looking parents yell “Keep riding! You need more exercise!” Most everyone who can basically sheltering in place. An ever-expanding menu of options for homeless people to have safer, uncrowded shelter and medical respite services.

Yet the seasons turn, cheery trees blossom along with Wordsworth’s “a crowd, a host, of golden daffodils.” Life goes on. That is part of why it is so surreal. We now have whatever the opposite of the Shakespearean “pathetic fallacy” should be called. Our current sunny, blithely beautiful weather in Seattle does not reflect the ominous, sober, frightened, shocked, and mournful mood that hangs like a dark and virus-laden cloud over our city.

In times of great stress and grief (this is, after all, a time of collective grief for everything we have already lost and anticipate losing), and trauma—of disaster— we need to support all of our first responders. Not just medics and frontline nurses, physicians, public health workers, emergency shelter staff and janitors. To self-plagiarize (from my book Soul Stories: Voices from the Margins):

“Artists and writers are cultural and spiritual first responders in a disaster: they aid in the attempt to make meaning out of catastrophe and chaos, to find ways to not only survive but also thrive in the midst of adversity.”

Views from Seattle-King County, COVID-19 Outbreak

Week #2 of the Seattle area COVID-19 outbreak with its dark cloud hanging over the city, the nation, and the world, here is what I know to be true:

  1. Know and follow credible, scientifically evidence-based public health recommendations such as washing your hands with soap and water for at least 20 seconds–or using alcohol-based hand sanitizer (if you are lucky enough to have bought some before every store sold out) and practice sensible social distancing…
  2. Nicely but firmly correct any misinformation and bigotry that comes your way.
  3. Only share information that is from verifiably credible, scientifically evidence-based public health experts. For me here in Seattle that includes Public Health–Seattle & King County and Washington State Department of Health.
  4. Avoid engaging in stupid, fruitless, politically or ideologically-charged arguments (repeat #2 above and this could be a positive way to practice a different kind of social distancing).
  5. Don’t just sit there (unless, of course, you are sick)–do something positive! Support our heroic front-line public health and health care workers like nurses, physicians, medics, and cleaning staff who are working around the clock to care for individuals, families, communities, and entire populations affected by this pandemic. Support our elderly, medically-vulnerable, and people experiencing homelessness. If you are able, volunteer to assist in these efforts.
  6. Remember to get outside or somewhere close to nature to smell the flowers.
  7. Be kind.
Burke-Gilman Trail near Children’s Hospital, Seattle

Nursing in the Time of Pandemics

Having come of age and been a nursing student during the early days of the HIV/AIDS pandemic, I have been feeling many moments of deja vu over the past month with the world-wide spread of the novel coronavirus and the accompanying COVID-19 illnesses. It is, of course, more than a distant global health issue now since I live, work, and teach nursing in Seattle-King County–site of the first death of a patient with COVID-19 and where experts now estimate at least 1,500 people are already infected. The two high-risk groups for severe complications and deaths from COVID-19 are healthcare providers and older people who have underlying chronic illnesses. I fall into one and a half of those categories, so I am concerned on a personal level.

But I am concerned on a larger level because I teach hundreds of nursing students and feel an urgent responsibility to help prepare and equip them to deal with this public health emergency. And not just the practical training and adequate access to the necessary medical supplies–on the use of personal protective equipment like face masks and goggles. But also the emotional and ethical preparation and support for processing a rapidly evolving, complicated pandemic. Acknowledgement that fear and anxiety are part of this but that we have a personal and professional duty to care for people despite that fear and without bias. I like the public health messaging that has gone out from our Public Health-Seattle & King County people: “Viruses Don’t Discriminate and Neither Should We.” Yet it goes beyond that, to an acknowledgement of weaknesses of our healthcare and public health system and resolve to do better, to learn from our mistakes–including from our mistakes in how we handled the HIV/AIDS pandemic. We cannot allow shallow, partisan politics, malicious misinformation, undermining of evidence-based public health interventions, and bigotry to fuel the spread of this virus.

Dorothea Dix and the Trade in Lunacy

Dorothea Dix, Harvard University Houghton Library

Dorothea Dix was a leading US and international mental health reformer. She knew how to wield her quill pen and do her own reporting to advocate for positive changes. We still have a lot to learn from her.

Starting in 1830 with her investigative reporting on the deplorable conditions of inmates at a Cambridge, Massachusetts jail, Dorothea Dix quickly spread her mental health advocacy efforts with inspections of prisons and insane asylums throughout Massachusetts and other states, then internationally to England and Scotland (petitioning Queen Victoria for reforms), France, Italy (petitioning Pope Pius IX), and Turkey (trying unsuccessfully to meet with and petition Florence Nightingale at the end of the Crimean War).

After Dix’s controversial stint as Superintendent of Women Nurses for the Union Army during the American Civil War, she again took up her mental health reform efforts extending them to the Far West, visiting California, up through Oregon, to Washington Territory. Remarking on the natural beauty of Washington, including snow-capped Mt. Rainier, she described in a letter to her British Quaker reform friends, the Rathbones of Liverpool, that she was favorably impressed by the Pacific Northwest’s “humane and liberal” prisons and insane asylums. She attributed their excellence to how newly settled the area was, a newness that allowed for more progressive thinking than in either European or the American East Coast cities.

Dix was involved with political debates raging in England and Scotland where local parishes used the contract system, paying for their insane poor to live and work in private, for-profit insane asylums. Many of the asylum proprietors cut costs and increased their profits by shackling patients inside unheated rooms and depriving them of food and medical care. Known as the “trade in lunacy,” once the truths of the trade were uncovered, the practice was a source of widespread moral outrage and calls for reform.

In America, there were claims that treatment of insane incurable paupers in state-run insane asylums was a more humane approach. Proponents claimed it would save money in the long run, given economies of scale and since patients could avoid being sent to higher-cost jails and prisons.
Early reports from institutions such as the Worcester Insane Asylum claimed high success rates of “curing” patients of their insanity, by citing high patient discharge rates. What they failed to mention were the equally high rates of readmission of these patients to the same or similar institutions within short periods of time. Once forced to face these statistics, proponents of insane asylums, including Dorothea Dix, began to point to “seasonable care,” meaning that successful treatment and cure rates occurred when patients were identified early in their illness and were provided with appropriate treatment at insane asylums. Early in their illness was typically defined as treatment within the first year of onset of their symptoms.

Public and private debates in America were raging as to whether paupers–insane or not–brought on their own plights through immoral acts such as intemperance, specifically in terms of alcohol consumption, and the duty of the state to care for such people. Calvinist work ethics and conceptions of sin and salvation colored these debates. Women with children “out of wedlock” and prostitutes were labeled as sinners and as undeserving poor. Leading reformers such as Dorothea Dix declared that the duty of society was the same whether insanity or destitution resulted from “a life of sin or pure misfortune.”

Sources:

Dorothea Lynde Dix, Asylum, Prison, and Poorhouse: The Writings and Reform Work of Dorothea Dix in Illinois (Carbondale, Ill.: Southern Illinois University Press, 1999).

Thomas J. Brown, Dorothea Dix: New England Reformer, Harvard Historical Studies ; v. 127 (Cambridge, Mass.: Harvard University Press, 1998).
Dix, Asylum, Prison, and Poorhouse.

Legislative Assembly of the Territory of Washington, “An Act Relating to the Support of the Poor.”

Tamonud Modak, Siddharth Sarkar, and Rajesh Sagar, “Dorothea Dix: A Proponent of Humane Treatment of Mentally Ill,” Journal of Mental Health and Human Behaviour 21, no. 1 (2016): 69, https://doi.org/10.4103/0971-8990.182088.

Dorothea Dix, “‘I Tell What I Have Seen’—The Reports of Asylum Reformer Dorothea Dix,” American Journal of Public Health 96, no. 4 (April 1, 2006): 622–24, https://doi.org/10.2105/AJPH.96.4.622.

Dorothea Lynde Dix, The Lady and the President: The Letters of Dorothea Dix & Millard Fillmore (Lexington: University Press of Kentucky, 1975).

Generosity in the 20s

“Changing the world may need to begin with a firm recognition that only the outward manifestation of our problems is new. We need respite from the present in order to return to it, and an active form of respite is seeing ourselves reflected in old stories. The good times have always been fleeting and poorly distributed. Looking back can be one form of moving on.” –Arthur W. Frank , astute and eloquent and timely… Sharing his recent blog post as it is powerful and important for all of us in these uncertain times.

Arthur W. Frank

So we all enter a new decade. I haven’t written recently, in part because of enjoying the holidays, and in part because I’ve been working hard to assimilate Simon Critchley and Jameson Webster’s The Hamlet Doctrine (now reissued as Stay Illusion). I finally read this book just as my article “‘Who’s There?’ A Vulnerable Reading of Hamlet” appears in Literature and Medicine (37.2, Fall 2019, 396-419, currently online). If I’d read Critchley and Jameson earlier (the book appeared just as I submitted the manuscript), I would have written a different article. Which may be what makes Hamlet perennial: more than maybe any story, it never stops opening into different understandings. C&J read Hamlet very differently from Harold Bloom, but they left me thinking that Bloom’s title gets the point of it: Poem Unlimited. But that’s an apology and update, not what I want to write about today.

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Start with Compassion

The unique Little Free Libraries around Seattle, including the one pictured here, are wonderful community assets. In a Little Free Library near my home I found, read, and returned a gorgeous hand-made journal intentionally left there by an older woman who is homeless. She considers these journals to be her published memoirs. I thank her for sharing her artistic and writerly talents, as well as her astute insights into the “homelessness industrial complex” of Seattle. Reading her journal provided me with a window into her world.

I admire the work of Seattle architect Rex Holbein, his daughter Jenn LaFreniere, and other people at the Seattle non-profit Facing Homelessness who help match homeless people, including homeless mothers with small children, with homeowners who have built backyard accessory dwellings for them. Called the “Block Project,” it has the motto “Yes, in my backyard,” as opposed to the usual “not in my backyard” NIMBY-ism. It requires the buy-in of people in the neighborhood, or at least the city block, where a formerly homeless person will live. Their aim is to have a homeless person or family supported by an entire community, recognizing that homelessness is not just “houselessness” as many advocates now claim. Homelessness is about the lack of interpersonal affiliations, connections, and supports that make a house a home. Although this is not something I can see myself doing anytime soon, I like that the Block Project and Facing Homelessness exist in my city. It gives me hope that we can become better versions of ourselves, a better version of our city.


In this I am reminded of the words of Rev. Craig Rennebohm, who began a still-thriving street-based mental health outreach program for homeless people in Seattle. I had the pleasure of interviewing him for the oral history component of my Skid Road project in February 2016. He said, “I realized that if we can’t bring some level of peace to our neighbors on the streets, in our communities, there’s no hope for us being a more peaceable presence in the world. We need to learn how to be peaceable and healing at the most fundamental levels of our common life–as families, as neighbors, as cities and towns–communities.”

Here’s to a peaceable and healing and compassionate year ahead.