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.

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).

The Long View

This, unfortunately, is the season for despair for far too many people in our country. We have the recent health policy and population health news that, for the third year in a row, life expectancy in the United States is going down. Our overall life expectancy began to stagnate in the 1980s, then decline for certain groups, and more recently to decline more broadly. (see: “‘There’s something terribly wrong’: Americans are dying young at alarming rates” by Joel Achenbach, The Washington Post, November 26, 2019)

And, as researchers point out, this decline cannot be blamed solely on the opioid epidemic. Neither can it be blamed on Democrats or Republicans. Diseases and deaths of despair in our country are something we are all responsible for, what we all can do something about.

History teaches us to take a long view. History training, in the words of one of my favorite contemporary British historians, David Hitchcock, is also “empathy training among other things.”

Recently, I have had the pleasure of immersing myself in the oral history interviews I have conducted with a variety of people working and living at the intersection of homelessness and health in Seattle-King County. You can view the names and photographs of the people I have interviewed so far for my Skid Road project, as well as a few videos, here.

As an antidote to despair, I offer you an excerpt from my interview with one of my mentors, the social worker and civic engagement teacher Nancy Amidei. This interview was conducted on June 16, 2015 at Jack Straw Cultural Center in Seattle. This was her response to my question of what gives her hope for the future:

“I’m old enough to be able to say that when I graduated from college, there was no Medicare, there was no Medicaid, there was no Head Start, there was no WIC [Women, Infants, and Children] program. Food stamps was a pilot demonstration project in seven counties. What else? Oh, school lunch was only in the schools that could afford it, only the rich schools. There was no senior nutrition program. There was no American with Disabilities Act. There was no Civil Rights Act. There was no Voting Rights Act. Oh, there were no women in professional sports because there was no Title IX.

So, if I had to guess, I think all of those things passed within maybe twenty years from when I graduated. Well, if you had lived through that kind of change and you’ve seen that happen–and most of that is stuff that helps people who are not rich, who are not powerful. Food stamp recipients are not rich and powerful. Welfare moms are not rich and powerful. We can do things in this country, and you don’t have to be rich and powerful to make it happen. But you do have to vote, and you do have to pay attention to who’s in office. You do have to pay attention to the candidates. And you do have to speak up.”

Homelessness Started Two Years Ago

Richmond, Virginia 1986. Covering up Homelessness

An important news update brought to you by President Trump: Homelessness started two years ago in our country and it is the fault of liberal states, of liberal people in sanctuary cities such as Los Angeles, San Fransisco, and New York. And Seattle. Oh yes, and our president claims that it is the fault of homeless people themselves. “They like living that way.”

“We’ve never had this in our lives,” he said in a FOX news interview with Tucker Carlson last week. When asked by Carlson what we should do about it Trump responded, “Take the (homeless) people and do something.” Presumably by that, he means clear homeless people away, dispose of them out of sight. Perhaps in detention centers along the US-Mexican border. Or behind rows of doors from torn-down affordable urban housing as in the photograph above from my hometown of Richmond, Virginia. I took that photograph in 1986 on my way to my work as a nurse with homeless people.

Trump pointed to his clearing out of homeless people in Washington, DC when he moved into the White House. He claims he told people that he had leaders of the world coming to see him, the President of the United States, and “they can’t be looking at that” referring to visible poverty and homelessness in our nation’s capital.

That this revisionist history, these lies, would be laughably absurd in a different context, a different time—perhaps sometime in our hopefully brighter future—is one thing. But that wistful and wishful thinking only highlights the current dangers in this rhetoric. People believe what Trump and Carlson say. People act on what Trump and Carlson say. “Take the (homeless) people and do something” leads to vigilantism and physical attacks (and killings) against people who are or who “look homeless.”

Let the Light In

Doorway Community Cafe

“Is there still a will in this country to make things better?” Ben Danielson, MD, director of the Seattle Children’s Odessa Brown Clinic asked this question a few days ago in a nursing course I co-teach. His question resonates with me as I firmly believe that we all have the responsibility to leave things better than we found them. It is all too easy to complain bitterly about a situation we find distasteful but not work to improve things.

That is why I am grateful for our interprofessional Doorway Project team, youth serving agencies, and the young people in Seattle who are working to bring the dream of a community cafe to reality. The photo above shows the iterative design rendering of the cafe space, along with Seattle sunshine coming through the imagined (and real) skylights from our pop-up cafe event this past week. The sticky notes have additions from participants. Their suggestions include such as a rooftop community garden, music, a small shower—and stuffed animals to hug.

Our Doorway team is tasked with the lofty goal of ending youth homelessness in Seattle’s University District. We’re doing this by working with young people who are “experts by experience”—and with the wider community—to design a community cafe space where everyone is welcome. And where young people are valued for who they are and for what they bring to the table: music, artwork, poetry, storytelling, and more.

Dr. Danielson admonished our students in class this week to “not be shy about stealing good ideas,” pointing out that things we think of as innovative have usually been done before. For the Doorway Community Cafe we are building on the model of the Merge Cafe in Auckland, New Zealand, as well as the Open Door Cafe in Edinburgh, Scotland. The work of our students and young people from the community on the Doorway Project gives me hope for the future.