Place-based Health and Well-being

P1010527 If you have to be poor and homeless, don’t be poor and homeless for long. If you have to be poor and homeless, learn how to fill out all of those food, health, and housing support forms before you become poor and homeless. If you have to be poor and homeless, chose carefully which city to be poor and homeless in.

That’s my take-home message from this past week’s top public health news stories, as well as from my recent trips to the underbellies of both Los Angeles and Cleveland. If I somehow were to become poor and homeless again, I would want to be poor and homeless in my adopted hometown of Seattle. Seattle has its problems, but as a major U.S. city, we somehow manage to do many things right.

First, the buzz created among health policy-minded people and even laypersons from a recent article in JAMA reporting research results indicating that individual health behaviors like smoking and lack of exercise among poor people in the U.S. are the most important correlates of their diminished life expectancy compared with higher income people.

The April 10, 2016 JAMA article, “The Association Between Income and Life Expectancy in the United States, 2001-2014” by Stanford University economist Raj Chetty and associates, used an impressively large dataset of 1.4 billion deidentified tax records; Social Security Administration death records; rates of self-reported smoking, obesity, and exercise from the CDC’s Behavioral Risk Factor Surveillance Survey; Medicaid claims data; national/regional data on major urban ‘commuting zones,’ urban area per capita government spending, fraction of the local population that are college graduates, average housing price, and level of socio-economic neighborhood segregation. The researchers claim to have found weak to no correlations between life expectancy and many of the classic social determinants of health, while finding a strong correlation between individual health behaviors (especially smoking) of the poor and life expectancy. Although, in digging into this quite dense article, it becomes apparent that being poor in some urban areas and regions of our country is much worse than in others. The 10 states with the lowest life expectancy for the poorest people form a belt across our country: Michigan, Ohio, Indiana, Kentucky, Tennessee, Arkansas, Oklahoma, and Kansas. Their data indicate that it is much better to be poor if you live in urban areas of California, New York, or Vermont. And they report that the strongest protective factors for people people include the percentage of recent immigrants (long known to be healthier when they first arrive to the U.S. but we somehow beat the healthy living out of them), higher local government expenditures per capita, and the fraction of the local population with college degrees.

Life expectancy was not shown to vary by access to most health care, but it was positively associated with level of preventive care. The level of residential segregation by socio-economic level mainly negatively impacted the life expectancy of people in the top income bracket. That finding should be getting much greater emphasis in the press: to all the richie-rich people who live in gated communities, believe in trickle-down economics, and do everything they can to avoid (or to invest in) impoverished areas near where they live, are paying the price by shortening their own life expectancies–and the life expectancies of their family members.

But it is important to read and digest the JAMA editorial in the same issue, “The Good Life: Working Together to Improve Population Health and Well-Being” by Steven H. Woolf and Jason Q. Parnell. As they astutely point out, the Chetty study has several major flaws (that, not surprisingly, were largely unnoticed and ignored by mainstream media). First, the researchers of the Chetty study used life expectancy at age 40 years instead of the more usual and robust life expectancy at birth. They also excluded people with no reportable income on federal taxes (thus, most all people experiencing homelessness), and they excluded people who live in rural or urban/commuting areas of less than 590,000 persons. Woolf and Parnell also point out that the Chetty, et al research report–and the way the researchers structured the study–“ignores both upstream determinants of individual health behaviors and the poor measurement of other pathways.”

Woolf (a physician) and Parnell go one to claim “that everyone seeks a good life,” of which health is an essential component, “but a good life also involves productive work, emotional and spiritual well-being, supportive social relationships, and a clean and safe environment. (…) Inequity, a term that can engender political controversy, is giving way to the language of opportunity and the more positive, bipartisan message that everyone deserves a fair chance at the American dream. Education is seen as an answer, not only for better health but also to combat poverty, crime, racism, the loss of blue-collar jobs, and many other social challenges. Many sectors are targeting early childhood, a pivotal age to shift life trajectories, giving children tools for success in education and careers and breaking the cycle of poverty while also preventing illness, behavioral disorders, substance abuse, and violent crime.” Woolf and Parnell exhort their (mainly) physician readers to use their “gravitas” to advocate for local improvements in the social determinants of health. They (annoyingly) leave out the essential role of nurses and all other members of the health care team. But, okay, it is JAMA after all.

Chetty was a researcher on an earlier study on variations in upward mobility of children growing up in different urban areas. In a July 22, 2013 NYT article, “In Climbing Income Ladder-Location Matters,” David Leonhardt used the study’s findings to compare children’s income mobility if they lived in Seattle versus Atlanta (at the time, the two cities had similar median incomes). Leonhardt writes, “The gaps can be stark. On average, fairly poor children in Seattle — those who grew up in the 25th percentile of the national income distribution — do as well financially when they grow up as middle-class children — those who grew up at the 50th percentile — from Atlanta.” The researchers of this study outlined four main factors which were linked with upward mobility for children growing up in poverty: 1) living in less socio-economically segregated neighborhoods, 2) living in a two-parent household, 3) access to better public elementary and high schools, and 4) higher levels of civic engagement, including in religious and community groups.

I leave you with some uplifting, positive, encouraging (and yes, nurse-centric) news related to this topic. The cost-effective, evidence-based Nurse-Family Partnership program is again in the news. I’ve written about this amazing program before (see “More Babies! Nurse-Family Partnership” January 29, 2012). The New Yorker, in a March 1, 2016 post titled “One of the Stranger Jobs in Texas,” links to a recent “The New Yorker Presents” film by Dawn Porter titled “Lone Star Nurse.” The film follows the work of former teen mother turned public health/ Nurse-Family Partnership nurse Nicole Schroeder as she visits “her girls” in Port Arthur, Texas. I say we need many more Nurse-Family Partnership nurses like Schroeder and much fewer high-end, elective surgery hospital nurses.

High Art, High Medicine, High Lead

Woman looking at art, Cleveland Museum of Art. Photo credit: Josephine Ensign/2016

Cleveland: the city of high art, high medicine, and high lead levels. Home of the amazing Cleveland Museum of Art, with its recent $350 million renovation, including a glass-enclosed atrium, the city’s largest free public space (at 39,000 square feet).

I spent the past week living in Cleveland, Ohio, in a hotel next to the Cleveland Clinic Hospital, one of our country’s premier high-end, high-tech medical complexes. It is, of course, a private health care entity. The last time I visited the Cleveland Clinic was in 1979 when I was a (blessedly only briefly) ‘cardiac patient,’ referred there by my Oberlin College clinic physician for a bothersome heart rhythm problem–probably precipitated by too much caffeine and studying of medical ethics. I remember being inside a dark brick building, and if the clinic space back then had any artwork to speak of, I certainly don’t remember it.

A few days ago, touring the art collection in the main Cleveland Clinic Hospital and guided by one of their art program curators, I was struck by how much of it is cold, clinical, and high-tech–matching, I was told, the overall branding image of the hospital system. I was standing inside the hospital space where surgeons recently had performed the first U.S.-based uterus transplant (significantly, I believe, in a married, Christian white woman and mother of adopted sons). Here are a few examples of the hospital’s prickly artwork:

‘The Ineffable Gardener and the Developed Seed” 2013, Stainless steel modules, by Lois Cacchini.

Untitled (Rooftop View) oil on masonite, 1957, by Hughie Lee-Smith. Cleveland Art Museum.

Cleveland is part of the Rust Belt now, and the town’s numerous boarded-up, crumbling factory buildings and houses are testament to the city’s economic decline. Cleveland is a city of 389,524 residents, the vast majority are African-American, and 39.2 of all residents live in poverty (the median household income is $24,701). Not surprisingly, the health care sector is Cleveland’s largest employer, with the arts also being a leading industry. (Source: Data USA from the MIT Media Lab–a great source of up-to-date and easy-to-use data visualization based on US government databases.)

When I checked into the Cleveland hotel at the start of my health humanities conference, a middle-aged white man from Germany was carrying a large container of bottled water. When I asked him about it he told me he’d read that Cleveland’s water supply was not safe and contained high lead levels, so he was buying his own water. He also told me he had flown in to be treated at the Cleveland Clinic.

Indeed, Cleveland has one of our nation’s worst problems with lead ‘poisoning’ but mainly from lead paint in deteriorating inner-city housing. The Cleveland neighborhood of Glenville, only blocks north of the Cleveland Clinic, had a 2014 study of lead levels in children under age 6 showing that 26.5% had levels exceeding the current CDC threshold of 5 micrograms per deciliter. (Source: NYT article “Flint is in the news, but lead poisoning is even worse in Cleveland” by Michael Wines, March 3, 2016.) Lead, as we know quite well by now, at any level is a brain poison that permanently decreases IQ and interferes with a person’s ability to control impulses. A different spin on the “No Child Left Behind Act.”

This photograph, taken from the top floor of the Cleveland Clinic Hospital and looking north towards Lake Erie, shows the downtown skyline to the left, and to the right (the darker, low-lying area) is the Glenville neighborhood. As I stood gazing at the Cleveland skyline from atop this very antiseptic and removed private hospital, I couldn’t help but wonder how anyone can possibly believe in trickle-down economics. To me it is the ultimate of self-serving delusions.

Homelessness Visible: A Photo Essay

House not for sale. Photo credit: Josephine Ensign, 2015.

The story of homelessness, visible, in my hometown of Seattle, told through photographs and a few accompanying words.

Here, on my daily walk in my neighborhood. Derelict housing, seemingly deserted, unless you know what to look for. Scattered clothing. A tattered backpack.

And this, a most unusual lawn ornament. The 700 metric ton glacial erratic ‘Lone Rock’ now known as the ‘Wedgewood Erratic.’ According to the City of Seattle, it is illegal to climb this rock. But I don’t think it is illegal to camp near it. Hence, this recent living room armchair. And a tent (removed during the day). In the background (the boxy building to the far right), note the supremely ugly new construction ‘single family home’ on the market for a mere $1.4 million dollars. In one of Seattle’s ‘working class’ neighborhoods.

P1010442 — ‘Lone Rock’ and Lone Chair, Seattle. Photo credit: Josephine Ensign, 2016

Yesterday, during a fierce windstorm, there was this homeless encampment in the doorway of an empty store at a busy intersection near my home. A man and a woman were working hard to keep their belongings from blowing away. Note the new (upscale) apartment buildings and the large crane in the hole that will be the new Roosevelt Light Rail Station.

Homeless in a Seattle Doorway. Photo credit: Josephine Ensign, 2016

And then there are the numerous unofficial ‘tent cities’ and other temporary shelters that all combine to make homelessness in Seattle very, very visible. In follow-up posts I’ll critique the current ‘state of emergency’ of homelessness declared by Seattle Mayor Ed Murray four months ago.

Man asleep in chair by Seattle city park. Photo credit: Josephine Ensign, 2015

Homeless encampment on Seattle sidewalk. Photo credit: Josephine Ensign, 2015

Where’s the Harm in Harm Reduction?

2016-01-15 18.00.54 — Photo credit: Josephine Ensign/2016

Harm reduction, properly applied, is a good public health and individual health strategy. Its focus is on reducing or minimizing harms to the individual, their partners, families, and communities–harms stemming from a whole range of ‘risky’ behaviors. This focus includes providing care in a non-shaming, empowering way, including through the use of motivational interviewing. Harm reduction principles and practices are most well-known for people using drugs and/or alcohol. There is the successful public health practice such as needle exchange in terms of reducing HIV and other blood-borne infections in communities–the lack of which was highlighted recently by the HIV-surge in Indiana. (See the May 16, 2015 NYT article by Carl Hulse, “Surge in cases of HIV tests US policy on needle exchanges.”) But harm reduction has been applied to other ‘risky’ behaviors, including tobacco adolescent sexual activity, and even for tattoos and body piercings.

I am all for harm reduction and have actively used this approach in my own work as a nurse practitioner for over twenty years. I am proud to live in Seattle-King County that is fairly enlightened in its public health approach utilizing at least some level of harm reduction.

But I have come to see the harm in harm reduction as applied to prostitution. What follows is the story of the evolution of my thinking about this topic, based on my work providing health care to homeless teens and young adults. It is an excerpt of my forthcoming medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (SWP, August 2016):

“A large number of our youth clinic patients worked in the sex industry as exotic dancers and prostitutes. Most came to clinic by themselves, some were brought in by their pimps, and a few young females came in with their male high school teachers who were fleeing other states on criminal sex charges. I was never sure which I found more despicable: the pimps or the teachers. The prostitutes were mostly young women, although there were also young men and transgender youth. We called it survival sex or just plain sex work, and erred on the side of nonintervention, harm reduction, trying to keep the young people as safe as possible until they could exit “the life.” This was a laudable goal and one I believed in. But in effect there were times we were supporting their lifestyle, enabling it, and becoming part of the problem. We mostly used the neutral term “sex worker” instead of “prostitute,” thinking it was more politically correct, more respectful of the young people involved.

I often asked myself: Is it possible for someone to be involved in commercial sex work and have healthy self-esteem? Is there such a thing as a happy, healthy hooker? Is the character Julia Roberts plays in Pretty Woman based on any sort of reality, or is she just part of a twisted fairy tale? I know prostitutes who call it a profession, who say they freely choose their work. I’d like to believe them because it would make my work easier. But their statements have the off-key clang of the false bravado I know so well, having used it myself over the years. So many young prostitutes have histories of previous sexual abuse as children. Their bodies are not their own; their bodies have been stolen from them. In such situations, free choice is not possible.”

Framing Homelessness

Rough sleeping in the U-District. Photo credit: Josephine Ensign/2016

Homelessness is in the news almost every day here in my hometown of Seattle. Unless you happen to live in a gated community and never go outside your protected home, there is scarcely a city block you walk without distinct signs of people living rough outside or in cars or RVs. It is no surprise then that our One Night Count of homelessness by the Seattle/King County Coalition on Homelessness last week found 4,505 people homeless/without shelter, a 19% increase from the One Night Count in January 2015. And this is despite the fact that the One Night Count volunteers (including a group of our UW Seattle nursing students) being unable to enter and count homeless people in ‘The Jungle,’ a longtime homeless encampment area in an I-5 greenbelt area of Seattle–and the location of our impressive Depression Era Hooverville. There had been a mass shooting in The Jungle the night before, resulting in the death of two homeless people and the hospitalization of three others.

Just two months ago, in November 2015, Seattle Mayor Ed Murray declared a state of emergency over homelessness, saying this in the official notice: “The City of Seattle, like many other cities across the country, is facing a homelessness crisis. The region’s current needs outweigh shelter capacity, leaving too many seniors, families and individuals sleeping on the street. More than 45 individuals have died while homeless on Seattle streets in 2015 alone.” His declaration of a state of emergency supposedly helps “deploy critical resources more quickly to those in need.”

Suddenly it begins to feel like we’ve entered a 1980s time-warp, with so many people weighing in with competing viewpoints, priorities, and proposed ‘fixes’ for our homelessness problem. I, of course, could add my own voice to the rising cacophony surrounding this latest round of the homelessness crisis. Instead, I offer these words of wisdom and perspective from some of my favorite deep and critical thinkers on the topic of the ‘first wave’ of modern homelessness in the 1980s:

“The scandal of homelessness looked as though it could harness a new politics of compassion and shame–compassion for the plight of the dispossessed and shame at the inhumanity of national and local policies toward them. Homelessness, in sum, had political appeal.” pp 132-133, in Donald Schon and Martin Rein’s excellent book, Frame Reflection: Toward the Resolution of Intractable Policy Controversies. Basic Books, 1994.
Put plainly, the opposite of homelessness is not shelter, but home. Understood culturally, ‘home’ must entail some claim to inclusion. The principled question underlying homelessness policy, then, is not, what does charity demand? but rather, what does solidarity require? And so it no longer suffices (if it ever did) to ask what it is about the homeless poor that accounts for their dispossession. One must also ask what it is about ‘the rest of us’ that has learned to ignore, then tolerate, only to grow weary of, and now seeks to banish from sight the ugly evidence of a social order gone badly awry.” p. 214 of Kim Hopper’s now classic book, Reckoning With Homelessness. Cornell UP, 2003.

Water, Water, Clean Water (not) Everywhere

2014-02-13 20.30.43 — Cook Strait ferry crossing, New Zealand. Photo credit: Josephine Ensign/2014

The public health (and political) crisis in Flint, Michigan over their contaminated drinking water should be sending out much louder alarm signals throughout our country. Snowmagedden 2016–from a different form of water–is drowning out the dirty water, dirty politics, and dirty failures of our public health system. Note my use of ‘our’ and not ‘their,’ which would make it oh so more comforting and at arm’s length for those of us who are not living in Flint. Contaminated water supplies can happen in our own hometowns, especially with the widespread crumbling infrastructures and a diminishing focus on public health surveillance. Access to safe, clean water is a basic human need; it should be an equal opportunity necessity. But clearly it is not.

For anyone who has missed this part of our national news, the Environmental Protection Agency (EPA) three days ago issued an emergency order over unsafe public water in Flint, Michigan, and assumed federal oversight of water testing and water treatment in the city of 100, 000–a city where 57% of the population is African-American and 42% of the city’s residents live below the poverty line. This week President Obama declared a state of emergency over the Flint water crisis and has assigned an expert from the Department of Health and Human Services to assist in assessing the extent of lead ‘poisoning’ in children and then recommend interventions. As we know all too well, what with the effects of lead additives to household paint and gasoline, as well as other environmental sources, children’s exposure to lead has devastating effects on multiple organ systems, and especially on the developing nervous system. Lead exposure in infants (including en utero) and children is linked with cognitive deficits (lower IQ), learning and behavioral issues.

In 2014, city and state officials switched from using the nearby Detroit water supplies (which came from the much cleaner Lake Huron) to using the highly contaminated Flint River for Flint’s water, in order to save money. They also failed to treat the water appropriately to minimize lead leaching into the water supply from old pipes. And they failed to appropriately test the household water supplies, ignored residents’ complaints about green and brown and foul-smelling water. And the city and state officials, including public health officials, publicly denied there was a problem, even after Dr. Mona Hanna-Attisha, a local pediatrician, presented them with evidence of alarmingly elevated blood lead levels in children she was seeing. As reported today in the excellent NYT article, “When the Water Turned Brown,” by Abby Goodnough, Monica Davey, and Mitch Smith:

“Yet interviews, documents and emails show that as every major decision was made over more than a year, officials at all levels of government acted in ways that contributed to the public health emergency and allowed it to persist for months. The government continued on its harmful course even after lead levels were found to be rising…”

People have rightfully pointed out that this is clearly a case of a willful neglect of environmental justice. If Flint, Michigan was more affluent and ‘more white’ it is highly unlikely that this problem would have started in the first place, or at least it would have been more quickly and more efficiently remedied. As the EPA defines ‘environmental justice’ on its website: “Environmental Justice is the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies. EPA has this goal for all communities and persons across this Nation. It will be achieved when everyone enjoys the same degree of protection from environmental and health hazards and equal access to the decision-making process to have a healthy environment in which to live, learn, and work.”

In his characteristic no-holds-barred truth-telling way, filmmaker and Flint native Michael Moore is calling for the arrest of Republican Governor of Michigan, Rick Snyder, claiming he helped create the water public health crisis in Flint. (See this MSNBC interview of Michael Moore by Chris Hayes, January 19, 2016.)

As a public health nurse, this complex and entirely preventable problem in Flint, makes me angry and sad. Not only because of the environmental injustice of it all. Not only for the longterm negative health consequences for the thousands of children of Flint exposed to lead through their town’s drinking water. Not only for the devastating effects on the parents of these children. But also because of how much it undermines any and all heard-earned trust people have in our public health system. That negatively affects the health and safety of all of us.

Boo on Nurse Jackie

Hospital_Pole I have just finished binge-watching all seven seasons of Showtime’s TV series Nurse Jackie. By the end of season three I was oh so sick of seeing all of those oval blue pills, supposedly the Oxycontin prescription pain killers the fictional character of ‘All Saints Hospital’ ER Nurse Jackie (played by Edie Falco) was hooked on. In the name of research for this blog post, I binged onwards through the next four seasons. I am relieved it is over. I am relieved, I’m sad to say, that Nurse Jackie seemingly dies of a street drug overdose in the penultimate episode. Please, do not revive Nurse Jackie; do not make a Nurse Jackie sequel.

Unless it is a Nurse Zoey show. Nurse Zoey (played by Merritt Wever) rocks, starting with her cute pink bunny scrubs, pink headband, and pink nursing notebook in Season One when she appears as a nursing student. We’ll ignore her improbable (and frankly, boring) love affair with hottie doctor what’s-his-name in Season Four. I like the character of Nurse Zoey so much better than Nurse Jackie, not because of Jackie’s addiction, but because Zoey is a more realistic and well-developed character. I’ve known, taught, and worked with quite a few Nurse Zoey’s many times and in many places (including in community health) over my nursing career. I love the freshness and zaniness of her outlook on nursing. I love her intelligence and inquisitiveness. I love her loyalty–and its limits–to the messiness that is her mentor Nurse Jackie. I love that towards the end of the show she is committed to becoming a nurse practitioner (and not, as the ER TV series character Nurse Abby Lockhardt–played by Maura Tierney–does and becomes a physician because she is “too smart to be just a nurse”).

What bothered me most about the character of Nurse Jackie was that she is not at all believable. Of course, addiction and especially addiction to prescription pain medications is all too common a problem for nurses (and physicians). There are many surveillance, intervention, treatment, and disciplinary programs in place at hospitals, clinics, and home health agencies to address this. Again, by point of TV show comparison, in the show ER, both Nurse-turned-physician Abby Lockhart and Dr. John Carter (played by Noah Wyle) have addictions: Lockhart is a recovering alcoholic who relapses, and Carter develops and then recovers from an addiction to prescription pain medicine. In both cases, the contributors to and consequences of their addictions are realistically portrayed.

The type and severity of the addiction Nurse Jackie supposedly has seems to have developed in a vacuum–maybe out of an on-the-job back injury–and she continues to function as some sort of super-hero, saintly nurse. That just does not happen. And what was with the Catholic/religious connections throughout the Nurse Jackie show? I tolerated it until in the final episode of season 7, where Nurse Jackie appears to be Mary Magdalene washing the feet of the IV-heroin user (is that supposed to be Jesus in disguise?) with some heavenly glow all around her. Please. I realize this is ‘just TV’ and that at least this show highlights the profession of nursing, but we can do so much better than this.

Sick Nurses

V0026904 Florence Nightingale. Photograph by Millbourn. — Creative Commons. Photograph by Millbourn. Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk

Within the profession of nursing, we have a long and distinguished line of sick nurses who write. There was, of course, the mother of all sick nurses, Florence Nightingale, who, after the Crimean War, took to her bed with a mysterious illness that lasted for the last thirty years of her life. It was during this time that she wrote prolifically–letters and missives to the War Office, health care and social reform reports, and her now famous book Notes on Nursing.

Was her illness neurasthenia (nervous exhaustion, an actual medical diagnosis until the 1930s)? Was it a clever ploy to draw sympathy and support for her zealous cause of reforming nursing, hospitals–indeed, all of health care? Was it a clever ploy to have more protected time for writing and reflecting on the state of the world in need of her reform? Was it–as was taught to nursing students as late as the 1970s–the effects of tertiary syphilis? Was it–as current medical historian Philip A. Mackowiak postulates–a combination of bipolar disorder, PTSD from the horrors of the war, ‘Crimean fever’/brucellosis contracted from contaminated milk while in Turkey–and finally, the most likely cause of her death at age 91, Alzheimer’s Disease? (From his book, Diagnosing Giants: Solving the Medical Mysteries of Thirteen Patients Who Changed the World, Oxford UP, 2013.)

As Lytton Strachey puts it in his wonderfully intelligent short biography of Florence Nightingale in Eminent Victorians (Bloomsbury Press, 1918): “Her illness, whatever it may have been, was certainly not inconvenient. (…) Lying on her sofa in the little upper room in South Street, she combined the intense vitality of a dominating woman of the world with the mysterious and romantic quality of a myth.”

Lady with the Lamp. Ministering angel. Pious Christian woman relieving suffering in the world. Nursing as a religious calling. These are the nursing myths we still live with. The nursing myths we as nurses–and especially as nurse writers–still perpetuate.

That’s what I kept thinking today as I read nurse and poet Cortney Davis‘ new book When the Nurse Becomes a Patient: A Story in Words and Images (The Kent State UP, 2015). Her book is part of the ‘Literature and Medicine’ series that includes the wonderful short story collection What’s Left Out by physician writer Jay Baruch. (Baruch’s book also happens to have one of my favorite book cover designs–check it out here.)

Cortney Davis is a seasoned nurse practitioner and a talented poet. I especially like her poem “What the Nurse Likes” included in the now almost classic book, Between the Heartbeats: Poetry and Prose by Nurses (edited by Davis and Judy Schaefer, U of Iowa Press, 1995). But over the past decade or so, Davis’ work has become stridently religious (Catholic) and proselytizing (anti-abortion among other matters). The fact that her latest book was published by a reputable (and secular) university press, and has just received the Book of the Year Award (for the category ‘Public Interest and Creative Works) by the American Journal of Nursing combined to make me look forward to reading the book.

When the Nurse Becomes a Patient tells the story–through pictures and words–of her experience with life-threatening complications of what was supposed to be routine day surgery in 2013. She had an extended hospital stay and then convalesce at home. Davis, a life-long writer, found that writing had ‘left her’ but that she was able to paint images of her illness experience.

The print version is a children’s picture book size and the printing quality of Davis’ twelve paintings depicting her illness is quite good. Favoring Davis’ poetry over her prose, I was disappointed to find that it was plain prose descriptions that accompanied each full-page image of the corresponding painting. Two of the prose/painting combinations, “On a Scale of One to Ten” and “My Husband Cares for Me Tenderly” are both quite powerful and effective at evoking important aspects of her individual-yet-universal illness experience. But most all of the remaining ten prose/paintings were over-the-top religious, what with Dark Nights of the Soul (parts one a two no less), last rites (with a priest figure), and and “Angel Band” with–yes–nurses as angels and the figure of a nun in full habit by the patient’s bedside. And, of course, there was the requisite redemptive suffering bit in “I Offer My Suffering.”

Davis, like everyone else, is free to have and write about their own personal religious beliefs. People who are ill are typically driven to face existential crises, which can lead them to deepen (or abandon) a personal faith. But books like this make me despair of nursing ever breaking free of its overly-pious Victorian roots. It’s something that I suspect even Florence Nightingale herself (pre-cognitive decline) would have wanted for nurses and for the profession of nursing. We are not angels and suffering is not redemptive.

Red Blanket Patients

Very Important Patient red blanket. Photo credit: Josephine Ensign/2016

Although one of our country’s founding principles centers on equality, we know that has always been a lofty goal, and one that conflicts with our real guiding principle of rugged individualism combined with economic competition.

Money talks. Money yells. Money gets you red blanket treatment in many of our country’s hospitals. I’m sure the ‘real’ red patient blankets are much prettier than the swatch of one I knitted and embroidered for this photo, but they do exist both literally and metaphorically–and historically. Red blanket treatment’ of patients has historical roots in pre-WWII emergency medicine practice: a red blanket was placed over a patient triaged as needing rapid transfer to a place of higher-level treatment and attention. Presumably, this older type of ‘red blanket treatment’ was done based primarily on medical need and not on patient socio-economic status.

A different version of ‘red blanket’ VIP (Very Important Patient) hospital practices seems to be proliferating. ‘In the NYT Op-ed article “How Hospitals Coddle the Rich” (October 26, 2015), by Shoa Clarke, a physician currently doing his residency at Brigham and Women’s and Boston Children’s hospitals, writes of his experience during medical school (at an unnamed but readily identifiable hospital in California–as in Stanford) of being introduced to the concept of tiered care in hospitals where hospital administrators draped wealthy patients in scarlet blankets to help ensure they got better care. “This is a red blanket patient,” one of his supervising physicians reportedly said. Such red blanket patients are fast-tracked and given preferential treatment based solely on their wealth and status.

In a follow-up post related to this topic on KevinMD, a dermatology resident physician and medical school classmate of Clarke’s, Joyce Park, contends that she has never seen red blanket VIP patients getting better hospital care than other patients. In her very telling statement, “I have not seen this happen, from the level of nursing all the way up to the attending physicians” she manages to sum up the worst of hospital hierarchy-think and to come across as impossibly naive. (“The Problem with VIPs in the Hospital”, November 15, 2015.) Of course VIP patients get better hospital care, at least in terms of an increase in prompt nursing attention (and probably much lower RN to patient staff ratios), as well as more ‘discretionary’ medical and surgical interventions.

What’s ironic with this equation is that while the improved nursing care translates to improved patient outcomes, an increase in medical surgical interventions typically translates to worse patient outcomes. When nurses go on strike, hospital patient mortality increases; when doctors and surgeons go on strike, hospital patient mortality decreases or stays the same. (See the recent multi-country research study results reported in the British Medical Journal, “What are the consequences when doctors strike?” by Metcalfe, Chowdhury, and Salim. November 25, 2015/ and “Evidence on the effects of nurses’ strikes” by Sarah Wright in The National Bureau of Economic Research.)

The reason for this difference most likely lies in the fact that more medical and surgical care does not mean better health care or better objective health outcomes. As reported in a 2012 Archives of Internal Medicine article, “The Cost of Satisfaction,” (by Fenton, Jerant, Bertakis, and Frank) a study using a nationally representative sample found that higher patient satisfaction (with physicians) was associated with increased inpatient utilization and with increased health care expenditures overall and for prescription drugs. Patients with the highest degree of satisfaction had significantly greater mortality risk. The researchers postulate that patients with more clout who can cajole their physicians into giving them more medications and more discretionary medical-surgical interventions may be more satisfied with their care by physicians, but are also more likely to die from iatrogenic causes.

Perhaps–even if you can afford VIP/concierge/red blanket patient care–you should think twice about what you are really buying. And perhaps as a country we should think about where we’re headed with such an increasingly stratified healthcare system.

Nurse Practitioners: An American Invention

Josephine Ensign (Bowdler then) at Cross-Over Clinic. From The Bon Secours Courier/St. Mary's Hospital June 1987. — Josephine Ensign (Bowdler then) at Cross-Over Clinic. From The Bon Secours Courier/St. Mary’s Hospital June 1987.

In celebration of the 50th Anniversary of the establishment of the role of nurse practitioners, I want to share an excerpt from my forthcoming book, Catching Homelessness (She Writes Press, August 9, 2016 publication date). Young people contemplating careers in nursing often ask me if I am happy I ‘became’ a nurse practitioner back in the early 1980s. My answer is always a qualified and honest, “yes, but it has not always been an easy role to work within–mainly due to the rigid medical hierarchy.” Yet of all the health care roles in existence today, if I had the chance to do it all again, I would–without any hesitation–become a nurse practitioner. We are a tough breed, willing to work on the medical margins, and we are here to stay.

Here is the excerpt from my book, in a chapter titled “Confederate Chess”:

“Nurse practitioners are an American invention, and specifically they are an invention of the American West. The nurse practitioner role was started by a Colorado nurse in the mid-1960s during President Johnson’s War on Poverty, when Medicaid and Medicare were established to extend health care to the poor and elderly. Even before this expansion of health care, there was a shortage of primary care physicians. At the same time there were many seasoned, capable nurses who were already providing basic health care to poor and underserved populations. A nurse-physician team developed the nurse practitioner role, adding additional course work and clinical training for nurses. With this, states began allowing nurse practitioners to diagnose and treat patients, including prescribing medications for common health problems.

Not surprisingly, the emergence of the nurse practitioner role met with the most resistance in states with higher physician to population ratios, and in states with more powerful and politically conservative physician lobbying groups. The nurse practitioner role was protested both within the medical and the nursing establishments. Physicians didn’t want nurses taking jobs from them, and nurses didn’t want other nurses having a more direct treatment role—more power and prestige—than they did. But the role caught on and spread throughout the country. Nurse practitioners didn’t get firmly established in Virginia until the mid-1980s when I completed my training.

Why nursing? I often asked myself, and people continued to ask me even after I became a nurse practitioner. It was as if any sane, intelligent, modern woman could not want to be a nurse. I had stumbled into nursing while a master’s student at Harvard University, studying medical ethics and taking courses in the School of Public Health. I was gravitating toward a public health degree, but was advised by one of my professors to go to either medical or nursing school first in order to get direct health care experience. I didn’t like the approach of mainline medicine, but also had a negative stereotype of nursing. The only nurses I knew worked in my rural family doctor’s office. They were stout, dull-witted, and wore silly starched white caps, overly-tight white polyester uniforms, and white support stockings that swished as their fleshy thighs rubbed together. But in graduate school at Harvard I sprained my ankle, and went to the student health clinic. I was seen by a kind and competent provider who spent time explaining what I should do to help my ankle recover. I was impressed and thought she was the best doctor I’d ever seen. Then she told me she was a nurse practitioner and explained what that was. My negative stereotype of nurses was challenged.”

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this: