Category: Ethics

The Criminalization of Poverty and Homelessness

Homeless encampment between I-5 and Harborview Medical Center. Photo credit: Josephine Ensign, 2020

As our country edges towards post-pandemic individual and community life, we see clear evidence of deepening economic and racial inequities. Any walk or drive through our urban areas, from Washington, DC to Los Angeles, reveals a steep rise in visible poverty and homelessness, especially for persons of color. With this rise comes an increased push to criminalize people for being homeless. From my nearly forty years as a nurse and researcher working with homeless populations, and my lived experience of homelessness as a young adult, I know that criminalizing poverty and homelessness does not work. It only worsens the problem.

Here in Seattle, which already had one of our nation’s highest rates of homelessness and income disparities before the pandemic, tents and other temporary living structures made of cast-off materials line the hillsides along I-5, appear on sidewalks, and in green spaces such as ravines and city parks. Cars, RVs, and trucks with screened off windows and windshields—the temporary homes of vehicle residents— dot the landscape. A house next door to my own home in a mixed-income neighborhood near the university where I work, has changed from being an informal refuge for homeless squatters to a ‘flipped’ single-family home currently on the market for $1.2 million.

Early in the Covid-19 pandemic, when we were asked to shelter at home and congregate living spaces such as emergency shelters were known to flame the spread of the virus, public health officials locally and nationally moved to limit shelter capacity and placed moratoriums on both evictions from housing and homeless encampment clearances. Motels were turned into Covid isolation and recovery units for unhoused people. Despite the motels and pauses on evictions, visible homelessness increased exponentially.

Eviction moratoriums, an effort to prevent a wave of new homelessness in the economic fallout from the pandemic, although being challenged, appear to have more staying power than the hold on encampment clearances. In February of this year, the city of Mercer Island, one of the highest income ZIP Codes in the Seattle-King County area, enacted legislation to ban camping in public parks. (1) The Auburn City Council recently passed more punitive anti-homelessness legislation, allowing the charging of criminal trespassing for people camping overnight on any city property. (2) People now face a $1,000 fine and/or 90 days in jail if they fail to follow through with individualized plans aimed at either moving them into housing or at least out of the jurisdiction. Council members who voted in favor of this criminal penalty characterize the new law as “compassionate accountability.” In Seattle, a group composed of mainly business people is calling their effort to resume encampment clearances “Compassionate Seattle.” (3) They aim to secure enough signatures to bring to vote a change in the Seattle City Charter requiring the city to provide more permanent, supportive housing and simultaneously to clear parks and other public spaces of homeless encampments by criminalizing them.

Criminalizing homelessness has a long history in our country despite the fact that it has never worked. As the National Law Center on Homelessness and Poverty documents, criminalization worsens homelessness and racial inequities by weighing down already impoverished people with hefty fines, jail sentences, and criminal records. (4, 5) Criminalization diverts money away from supportive housing, and basic health—including mental health and substance use disorder treatment—that are more cost-effective at preventing and addressing homelessness. Communities that criminalize homelessness have higher rates of violence against people living or even appearing to be homeless. (6)

If criminalizing homelessness does not work, why do we keep returning to it? Part of the reason has to do with the fact that it was foundational to our country. Our various state-level poor laws, including vagrancy laws, are based on the Elizabethan Poor Laws adopted by the original thirteen British colonies. British social historian David Hitchcock points out that “Christian charity and proper punishment were delicately connected in English culture,” a connection reflected in the English Poor Laws. (7) English paupers were sent to the colonies as punishment, in what Hitchcock terms “welfare colonialism.” (8)

Benjamin Franklin, the vocal proponent of the “pull yourself up by your bootstraps” American metaphor of personal transformation through hard work, openly despised poor people and advocated for sending them to the western frontier, which at that time was Western Pennsylvania. (9) Franklin viewed this practice as a survival-of-the-fittest sort of endeavor that would simultaneously rid the East Coast cities of urban blight and disease, force the assimilation of immigrants, and improve the character and hardiness of Americans.

This westering, frontier mentality has reverberations today in Seattle, from the increase in Tiny House Villages looking eerily like the shacktown Hoovervilles of the Great Depression, to the burgeoning vehicle residents similar to the Dust Bowl’s Rubber Tramps who lined city parks, as well as the RV residents depicted in “Nomadland.” Recently, a team of human rights lawyers invoked the frontier-era Homestead Act of 1862 in King County Superior Court. (10) They were representing a homeless construction worker who lived in his truck against the city of Seattle for impounding his truck and charging him $557 in impound fees. (The city of Seattle appealed the ruling to the Washington Supreme Court, which heard arguments on March 16, with a ruling expected within a few months.)

Punishing people for being down and out and homeless is not the answer. Increased and sustained funding for safe, affordable, supportive housing, well-connected with primary health care that is inclusive of mental health and substance use treatment, is what works to address homelessness. Policies and programs led by people with the lived experience of homelessness make them more innovative and effective.

Sources:

1. Sydney Brownstone, “Auburn City Council votes to create criminal penalty for camping on city property,” The Seattle Times, April 19, 2021, https://www.seattletimes.com/seattle-news/homeless/auburn-city-council-creates-criminal-penalty-for-camping-on-city-property/.

2.Paige Cornwell, “Mercer Island restricts camping on public property in near-unanimous vote,” The Seattle Times, February 16, 2021, https://www.seattletimes.com/seattle-news/eastside/in-near-unanimous-vote-mercer-island-restricts-camping-on-public-property/.

3. Daniel Beekman and Scott Greenstone, “Proposal to address homelessness in Seattle city charter met with intrigue, skepticism,” The Seattle Times, April 13 2021, https://www.seattletimes.com/seattle-news/politics/seattle-begins-to-digest-proposal-that-would-change-city-charter-to-address-homelessness/.

4. National Law Center on Homelessness and Poverty, “Housing Not Handcuffs: What is Criminalization of Homelessness?” https://nlchp.org/wp-content/uploads/2018/10/criminalization-one-pager.pdf, accessed 4-29-21.

5. Joseph W. Mead and Sara Rankin, “Why turning homelessness into a crime is cruel and costly,” The Conversation, June 20, 2018, https://theconversation.com/why-turning-homelessness-into-a-crime-is-cruel-and-costly-97290

6.National Coalition for the Homeless, “No Safe Street: A Survey of Violence Committed Against Homeless People,” https://nationalhomeless.org/no-safe-place/, accessed 4-29-21.

7. David Hitchcock, “’Punishment Is All the Charity That the Law Affordith Them’: Penal Transportation, Vagrancy, and the Charitable Impulse in the British Atlantic, c. 1600-1750,” New Global Studies 12, no. 2 (2018): 195-215 (quote, 200), https//doi.org/10.1515/ngs-2018-0029.

8. Hitchcock.

9. Nancy Isenberg, White Trash: The 400-year Untold History of Class in America, (New York: Viking, 2016)

10. Ann LoGerfo and Ali Bilow, “Washington Supreme Court to Hear Oral Argument March 16 in Case Concerning Seattle’s Practice of Impounding Vehicles Used as Homes,” Columbia Legal Services, https://columbialegal.org/impact_litigations/city-of-seattle-v-steven-long-2/.

Deafening Silence: Teaching in a Time of Hate

I teach at a major public university that has yet to issue any statement about or even an acknowledgement of the appalling white supremacist mob attack on the United States Capitol two days ago, a mob directly incited by our current president. I teach at a university whose administration has allowed white supremacist hate groups on campus to openly recruit and brainwash students and distribute racist materials. (see my blog post, “Teaching in a Time of Hate and Violence.”) I teach at a school of nursing that has yet to issue any statement about this week’s life and history-altering events. Why the deafening silence?

Schools, colleges, and universities have a responsibility to respond promptly to crises such as the one we all find ourselves in. Students, faculty, and staff need to hear from leaders. I found myself in the position yesterday, in our first day of a winter quarter course on health equity (including racism) talking with students about Wednesday’s events, reviewing mental health resources, and letting them know that if something like that unfolds during any of our class sessions to feel free to bow out of class to take care of themselves and their loved ones. I also reminded us that health, individual and population-level, is only possible in times of peace and a functioning civil society. Teaching and learning are only possible in times of peace and a functioning civil society, with clear and competent leadership.

Note: After writing this post, I was alerted (indirectly) by someone in President Cauce’s office that she made this statement/blog post on her UW webpage on Wednesday, but no UW internal e-mail message was sent to students/faculty/staff. None of the students or colleagues I work with knew about/had seen her message. Which does beg the question of crisis communication…

Not Playing Indian

November is both Native American Heritage Month and National Homeless Youth Awareness Month. This week (November 15-22, 2020) is Hunger and Homelessness Awareness Week. Especially this year, in the midst of the pandemic disproportionately affecting Native Americans and other BIPOC people, rising joblessness, increasing evictions (despite CDC and other anti-eviction mandates), increasing domestic violence, increasing social isolation and depression among our teens/young adults, increased attention and action related to these social and health issues are important. There are many things we can all do to help. Here is my list of actions for you and your family members to consider doing—not only during November:

1. Become better informed about these national and local issues by reading through the resources included in the links above.

2. Read more books by Native Americans. My current favorites include Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge, and the Teachings of Plants by Robin Wall Kimmerer; There There by Tommy Orange, and An Indigenous Peoples’ History of the United States by Roxanne Dunbar-Ortiz.

3. Support Native American/Indigenous owned and run social service programs, such as Chief Seattle here in Seattle. They have health and social services (including supportive housing) for urban Native Americans/Native Alaskans/Indigenous people experiencing homelessness.

4. Support Native American/Indigenous owned and run arts and crafts stores, such as the “Inspired Natives, Not Native Inspired” Eighth Generation located in Pike Place Market, Seattle.

5. Support the expansion of school nurses and mental health counselors in all of our schools.

6. Support upstream policy efforts to prevent homelessness and hunger in our country. National Low Income Housing Coalition is one source of information on these issues. Likewise, for health and homelessness national policy issues, the National Health Care for the Homeless Council is an excellent resource.

Here is a digital storytelling video I made this summer in a StoryCenter workshop. “Honor Their Stories” is about my experience researching and writing a book chapter (in Skid Road: On the Frontier of Health and Homelessness in an American City, JHU Press, 2021) on Kikisoblu, also known as Princess Angeline, who was the daughter of Chief Seattle for whom Seattle is named. In this video, I explore the ethical issues I encountered as a white woman trying to understand more of the life, and death, of a Native American woman.

Nurses: Please Vote

Nurses in the United States: Please do not sit this election out. Do your duty as an American citizen and as a nurse. Make informed decisions about candidates and issues and cast your ballot (just once, that is—don’t listen to our current president, silly man that he is, only vote once, whether it is by mail or in person or via e-mail for oversees folks). Voting is always important and is a sacred civic duty. This year, it is especially crucial for the health and future of our country. And do whatever you can to encourage and enable other people to vote, including your patients and your community members.

If you happen to be a nurse educator as I am, remember that you can and should provide course content on the importance of political knowledge and advocacy for nursing. It seems to be a common misperception among nurse educators that political content is somehow a no-no and that it can get them in trouble with their employers. Providing non-partisan information on being an informed voter is never a no-no. And, our nursing students need to be exposed to nursing faculty and other mentors who are politically engaged—including nurses who run for political office at the local, state, and national levels. A great non-partisan resource is the All In Campus Democracy Challenge. Check to see if your college/university has signed on to this challenge and what resources and activities you can tap into.

In just a few weeks, I will cast my ballot here in Seattle, King County, Washington. I am proud of our state and county for ensuring that our elections are safe and open to every eligible voter, no matter their race/ethnicity, country of origin, language, able-ness, and political affiliation. I am proud to be part of the grassroots Nurses for Biden-Harris group, working to promote information on the reasons why nurses should strongly consider voting for the Biden-Harris ticket: compassion, faith, resilience, empathy, kindness, humility, joy, respect, inclusion, and dignity. Those are the core values of Joe Biden and Kamala Harris. They also happen to be core values and part of the Nursing Code of Ethics of the American Nursing Association.

Racism and Nursing

Bandaging a patient’s hand, Cross-Over Clinic, 1986. Richmond Times-Dispatch

Ibram Kendi writes, “We are surrounded by racial inequity, as visible as the law, as hidden as our private thoughts. The question for each of us is: What side of history will we stand on?” (How to Be an Antiracist, p. 22).

In preparing to teach population health nursing and health policy and politics again this coming academic year, I am working with the good folks at StoryCenter to develop media literacy content utilizing digital storytelling videos. And, since our University of Washington Health Sciences Common book will be Kendi’s How to Be and Antiracist (not to mention the current moment in terms of racism in our country), I plan to use digital storytelling focusing on racism and bias in nursing and health care.

Nurstory, working with StoryCenter, has some excellent digital storytelling videos by nurses across the country, including nurses with the Nurse Family Partnership. Dr. Raeanne Leblanc and her colleagues at University of Massachusetts, Amherst, completed a Nurstory project on social justice. My plan is to work with our students on the use and making of digital stories related to racism and bias. Since I believe that I should practice what I preach (or teach in this case), I recently made a digital storytelling video on my experience of racism in various aspects of nursing, including nurse education. Titled “Relics,” here it is:

Relics, Josephine Ensign, August 2020

Protect and Support DACA

In this time of justifiable anger, protest, and civil unrest, let us not forget other ways that the rights of persons of color are being undermined in our country. DACA: Deferred Action for Childhood Arrivals is an Obama-era program that gives temporary legal status and work permits to undocumented immigrants who came to our country as children. The vast majority of DACA recipients are young people of color and many of them work as nurses and other essential workers. (see “Washington’s DACA recipients on the coronavirus frontline await Supreme Court ruling” Nina Shapiro, The Seattle Times, May 31, 2020)

The Trump administration, big on building walls and racial/ethnic/political divisions in our country, has been trying to dismantle DACA. The NAACP is a staunch supporter of DACA. The Supreme Court is set to rule on a major DACA case any day now. In fact, they were expected to release their ruling today but likely delayed it in case their ruling fuels further protests.

At least one of my nursing students this year is a DACA recipient. It has been an honor to be one of her teachers. With her permission (and her group members’ permission), I share this powerful digital storytelling/health policy video: “Barriers to Health Care for DACA Recipients: Yohannah’s Story.”

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).

Exposed: The Ethics of Storytelling

“Streetwise Revisited: A 30-year Journey” exhibition, Seattle Public Library, 2016

“I want people to think of me as being this thirteen-year-old little girl that raised myself on the streets and survived through a lot of stuff like the Green River Killer, and other people that were crazy and through me shootin’ dope and never died. Cleaning up my life and having my kids and doing the best I can do.” Erin Blackwell, street name “Tiny” in a 2014 interview with the late master photographer Mary Ellen Mark (1940-2015)

I am revisiting the story of Erin Blackwell, a Seattle woman who, as a then thirteen-year-old prostituted teen in downtown Seattle, was the focus of an influential documentary and accompanying book on the “street kid” phenomenon of the 1980’s: Streetwise (1984) by Martin Bell (documentary) and Mary Ellen Mark (book). I also am revisiting and extending my thinking about the complex ethics involved in storytelling, whether that is through photography, film, or—in my case—writing.

Specifically, I am wrestling with the ethical issues involved in my research and writing of my current Skid Road book project’s chapter, tentatively titled “Streetwise” (now retitled “Threshold”) and based on the story of Tiny. Since my book project is a narrative history of homelessness and health in Seattle, all of my previous chapters have focused on the story of a ‘real life’ Seattleite who lived and/or worked at the intersection of health and homelessness. But all my my main characters up until “Streetwise” are now dead. The fact that they are dead obviously does not let me off the hook from being respectful of who they were as people—respectful of their memories and their legacies, including living relatives.

But Tiny—Erin Blackwell, who is very much alive and still living in the Seattle area. How do I go about ‘using’ her story as the basis of exploring the complexities of the homelessness crisis—particularly the youth homelessness crisis— in our nation and in Seattle in the 1980’s and 1990’s?

Since I moved to and began my work with Seattle homeless youth in 1994, I have come to know a fair number of the homeless youth depicted in Streetwise. I’ve also worked with social workers and other care providers who were involved in one way or another with Streetwise. Thus, I am privy to insider information, much of which is not in the public domain. That, I know, will not make its way directly into my book but it will end up in it at least indirectly. I have completed ‘official’ oral history interviews with the health and social care providers. I’m still wondering whether or not I want to try to interview Erin for this chapter. Somehow it does not feel right to ask her to expose herself more than she already has.

****

More information on Streetwise and “Streetwise Revisited: A 30-year Journey” exhibition in fall 2016 at the Seattle Public Library can be found at Seattle University’s excellent Project on Family Homelessness website.

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? 

Stolen Stories

P1020721Telling the story of trauma—of survival—may have the capacity to at least aid in healing at the individual level, but then there is the added danger, once the story is shared, of it being appropriated and misused by more powerful political or fundraising causes. Stories can be stolen. Arthur Frank calls these “hijacked narratives—”Telling one’s own story is good, but it is never inherently good, and the story is never entirely one’s own.” (1)

An intriguing example of a stolen story is the one explored in Rebecca Skloot’s narrative nonfiction book The Immortal Life of Henrietta Lacks, a book that tells the story of the cervical cancer cells “stolen” from an impoverished and poorly educated black woman in Baltimore in the 1950s. Scientists at Johns Hopkins Hospital subsequently profited from culturing and selling these HeLa cells—cells which killed Henrietta Lacks, cells which neither she nor her family members consented to anyone using or profiting from. Skloot, a highly educated white woman, has also now profited from the use of the Lacks’ family story, although she has set up a scholarship fund for the Lacks family members.

I am reminded of the proverb that Vanessa Northington Gamble shares in her moving essay, “Subcutaneous Scars,” written about her experience of racism as a black physician. Dr. Gamble’s grandmother, a poor black woman in Philadelphia, used to admonish her, “The three most important things you own in this world are your name, your word, and your story. Be careful who you tell your story to.” (2)

**The above is an excerpt from my chapter/essay “The Body Remembers” from my book Soul Stories: Voices from the Margins (San Francisco: The University of California Medical Humanities Press, 2018) page 81.

  1. Arthur W. Frank “Tricksters and Truth Tellers: Narrating Illness in the Age of Authenticity and Appropriation,” Literature and Medicine 28 no. 2 (Fall 2009): 185-99, page 196.
  2. Vanessa Northington Gamble, “Subcutaneous Scars,” Health Affairs 19, no.1 (February 2000): 164-69, page 169.