Safe Sleep Matters

IMG_8022Good sleep supports good health, including mental health. We’ve all experienced sleep disruption and sleep deprivation at some point in our lives. Pulling ‘all-nighters’ while cramming for exams in school. Being a new parent. Being a caregiver for someone ill or injured. Being a night-shift nurse or other worker. Times of insomnia. We know from experience that not getting enough sleep can make us cranky at best and dangerous to ourselves and others at worst (as with driving-while-fatigued). So why, as a society, do we insist on making it a crime for homeless people to sleep, or even to simply rest?

This morning, while walking my dog in my Seattle neighborhood, I passed a small public park where a man dressed in ragged clothes lay sleeping in the shade of one of our lovely Pacific Northwest conifers. It is a hot day, and it gladdened my heart that when I passed him again several hours later on my way home, someone had placed bottled water near him–and he was stirring, reaching for the water. And no police officer was shooing him away. An increasing number of cities are criminalizing homelessness, including passing tough anti-loitering laws for public parks and sidewalks.

For anyone who has ever been homeless, or who takes the time to talk with and understand more of the lives of people experiencing homelessness, finding a safe place to sleep is one of the biggest difficulties. People who are homeless and are rough-sleeping are at great risk of being victims of crime, including of targeted hate crime (although homelessness is not a ‘protected’ category under federal hate crime laws). Whatever meager belongings they have are at risk of being stolen. Women are especially vulnerable to sexual assaults while they are sleeping or resting.

That is why I was heartened on my recent stay in Portland, Oregon to be able to visit the consumer-run nonprofit group Right to Dream Too. This is how they describe what they do and why they do it :”Right2DreamToo (R2DToo) was established on World Homeless Action Day, Oct. 10th, 2011. We are a nonprofit organization operating a space that provides refuge and a safe space to rest or sleep undisturbed for Portland’s unhoused community who cannot access affordable housing or shelter. We exist to awaken social and political groups to the importance of safe undisturbed sleep.”

The city corner lot where Right to Dream Too is located is a noisy one, what with being on a busy street (Burnside) and with wrecking balls whacking down buildings all around them. Yet it is an amazingly welcoming and peaceful oasis inside. A check-in desk, people doing shifts of self-policing the area for security, a small eating area next to a couch and bookshelves filled with books. Covered, airy gym-type thick mats raised on pallets where people can sleep. Neatly stacked piles of sleeping bags and pillows. (They told me that most of their budget goes towards laundry for the bedding). Tents in the back for staff members who stay there longer term. Well-maintained port-a-potties. Flower boxes. Brightly painted cast-off doors around the perimeter. Donated bicycles and clothing. A special tent filled with computers and information on job-hunting and health, social, education, and legal services. A palpable sense of peace and community. And even a small community garden!

The five-year-old program is, of course, at continual odds with the various powers that be in Portland and are soon to be moved to another site out of the downtown core–less convenient for the ‘houseless’ consumers of their services, more convenient to the downtown developers, condo and business owners. Here are some photographs I took of my visit (with their permission).

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Summer Reading Challenge 2016

IMG_7812Reading through the recent NYT article “12 New Books We’re Reading this Summer (and 6 Not So New),” with the list of summer reading by their book critics and staff, I was reminded that it is time to come up with my own summer reading challenge book list with a health humanities and social justice slant. Also, I was reminded to come up with a more diverse reading list than the one offered by the NYT. I did  similar list last summer (see previous blog post, Summer Reading Challenge with a Health Humanities/Social Justice slant ( June 2, 2015), with subsequent posts on my reading progress and reviews of the books.

My Summer 2016 Reading Challenge list of fifteen books is mainly composed of books I’ve acquired over the past few months during my cross-country travels, as well as from both the Association of Writers and Writers Programs (AWP) Conference in Los Angeles and the Health Humanities Consortium meeting in Cleveland. Four of the books on my list are truly ‘new’ books and the rest are new-to-me books. Here they are, listed from the bottom up as shown in the photo above:

Happy and thoughtful and humanistic summer reading everyone!

Carrying Stories: Beyond Self Care

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Girl with Balloon, street art by Banksy. This one found at intersection of K-Road and Queen Street in Auckland, New Zealand. Photo credit: Josephine Ensign/2015.

What to do with difficult stories? Stories of refugees, victims of mass shootings, of hate crimes, of rape, of torture victims, of people dying alone and unnoticed ?  It all gets overwhelming and depressing to hear or read these sorts of difficult stories, to carry them in our hearts, to bear witness to so much suffering in the world.

Of course, for many fortunate (perhaps unfortunate?) people, there is the option of tuning out these stories, turning off the news, unplugging from any non-vacuous form of social media. Taking a break from difficult stories.

But what about all the other people who cannot or choose not to disconnect? What about people whose work involves listening to these stories on a daily basis? Frontline health care providers who work with people experiencing trauma (physical, emotional, sexual). First responders. Counselors, mental health therapists, lawyers. Human rights activists. Researchers working on social justice issues. What can they do to, if not prevent, at least deal effectively with, vicarious or secondary trauma? And for those of us who teach/train/mentor students in these roles, how do we prepare students to be able to carry difficult stories while maintaining well-being?

In a previous blog post, “Burnout and Crazy Cat Ladies,” I explored the issue of ‘too much empathy’ and of pathological altruism, linking to some of the (then/2011) current research. After writing that post and some related essays, I began incorporating a new set of in-class reflective writing prompts for soon-to-be nurses in my community/public health course. I used these in a class session I titled “Public Health Ethics, Boundaries, and Burnout.”

The first writing prompt: ‘What draws you to work in health care? What motivates or compels you to do this work?’ And then later in the class session– after discussing professional boundaries (how fuzzy they can be), individual and systems-level risk factors for burnout, and asking them to reflect on how they know when they are getting too close to a patient, a community, or an issue–I gave them the follow-up writing prompt: ‘Referring back to what you wrote about what draws you to work in health care, what do you think are the biggest potential sources of burnout for you? And what might you be able to do about them?’

Feedback from students about this in-class reflective writing exercise and the accompanying class content on boundaries and burnout, was invariably positive. Many of them said it was the first time in their almost two years of nursing education that anyone had addressed these issues. I understand that patient care, electrolyte balances, wound care and all the rest of basic nursing education takes priority, but it makes me sad that we don’t include this, to me what is fundamental and essential, content.

“…people who really don’t care are rarely vulnerable to burnout. Psychopaths don’t burn out. There are no burned-out tyrants or dictators. Only people who do care can get to this level of numbness,” Rachel Naomi Remen, MD reminds us in her book, Kitchen Table Wisdom: Stories That Heal (Riverhead Books, 1996). Something to remember when we are feeling overwhelmed by difficult stories.

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Here are some excellent resources:

 

Creating Change

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Part of the timeline of slavery, racism and related issues. On the wall at entrance to UW Hogness Auditorium for the Health Sciences Service-Learning and Advocacy/Common Book Kick-off event, 10-6-15.

This past week at the University of Washington Health Sciences Common Book kick-off event, I heard a moving speech by Benjamin Danielson, MD. Dr. Danielson is Medical Director at Odessa Brown Children’s Clinic, a Seattle Children’s community-based clinic in Seattle’s Central District, an area which because of ‘redlining’/racial segregation in Seattle’s history, had been a predominantly black neighborhood. (see the excellent short video “A Really Nice Place to Live” by Shaun Scott). Odessa Brown is co-located in a building with its sister clinic, Carolyn Downs Family Medical Center, a clinic I worked at for five or six years. I had the pleasure of working with Dr. Danielson while coordinating care for a teen with sickle-cell anemia, and I know first-hand what an exquisitely competent and compassionate physician he is. But this week was the first time I’d witnessed his powerful public speaking abilities.

Our UW Health Sciences Common Book this year is Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Time of Colorblindness (The New Press, 2010). This is the fourth year we have had a UW Health Sciences Common Book, with interprofessional activities based on the book’s theme interspersed throughout the academic year. Previous books have been Anne Fadiman’s The Spirit Catches You and You Fall Down (a classic if not a bit ‘overdone’ by now), Gabor Mate’s In the Realm of the Hungry Ghosts: Close Encounters with Addiction (great topic but his book is in need of heavy editing–he rambles), and last year’s book was Seth Holmes’ Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States (great topic but read like a doctoral dissertation–which it was). The New Jim Crow is written in an accessible, non-academic and powerful style, and is, of course, on a painfully current topic in the U.S. and one pertinent to health care inequities: racism.

Dr. Danielson started his talk by acknowledging the history of the Central District where he works, and the ‘strong black women,’ of the neighborhood’s past, Odessa Brown and Carolyn Downs, for whom the two community clinics are named after. Both women advocated for quality and accessible health care for their communities. Odessa Brown, who had experienced racial discrimination in accessing health care, was active in starting a children’s clinic in the Central District before she died at age 49 of leukemia. Kudos to the Odessa Brown Children’s Clinic for including information on Odessa Brown (the woman) on their front webpage, in ‘Our History,’ right under ‘Our Mission.’

Carolyn Downs was part of the Seattle Black Panther movement, who with the financial help from people like Jimi Hendrix and James Brown (both from the Central District), in 1968 opened what was then the first health clinic in the community. Less of her history is included on the webpage for the clinic, but I know from having worked there and taking care of the daughter and granddaughter of Carolyn Downs, that she died young of breast cancer–and at least partially because of disparities in access to breast cancer screening and treatment.

I provide some of the history of both Odessa Brown and Carolyn Downs because I admire the work they did during their too-short lives, and because–as Dr. Danielson said in his speech–this can become another example of “black people being deleted from history.”

What to do about the continued, pervasive, and destructive problem of racism in our society, including in our institutions ranging from prisons to hospitals and clinics? The main message from Dr. Danielson and Michelle Alexander (through her book) is that it will take both individual and collective action for us (for the U.S.) to create positive change. During his talk, Dr. Danielson spoke of using the companion community organizing guide to The New Jim Crow, titled Building a Movement to End the New Jim Crow: An Organizing Guide by Daniel Hunter (Veterans of Hope Project, 2015).

In chapter one of this guide, “Roles in Movement-Building,” Hunter references the terminology used by Bill Moyer in his book Doing Democracy: The MAP Model for Organizing Social Movements (New Society Publishers, 2001) This work divides people’s roles into four main groups: 1) Helpers–direct service providers, 2) Advocates-who work to make systems work better for those in need, 3) Organizers–who bring people together to change systems, and 4) Rebels–who speak truth to power and agitate for radical change. The key is to recognize our own strengths and roles–where we are most comfortable working– but also to see the value in the rage of roles played by different people, because an effective social change movement requires people working in all of these roles.

This is similar to the “Bridging the Gap Between Service, Activism, and Politics” group activity from the Bonner training curriculum that I have used for many years when teaching community health. But (of course!) I like the addition of the category ‘Rebels’ to the mix and plan to add that the next time I use this in teaching.

On a very sobering (as if we weren’t already very sober) note, Dr. Danielson ended his talk Tuesday night by adding that for all the good work and innovative community outreach programs of the Odessa Brown Clinic, he often asks himself if they aren’t keeping children healthy enough that they too can end up in our country’s prison system.

The Kiwi ‘Can Do’ Community Cafe

IMG_5776As I prepare to leave New Zealand to return to my hometown of Seattle, I reflect on some of  the innovative programs and people working to address the growing problem of homelessness here in the land of milk and honey (and insanely good chocolate).

Yesterday I had lunch, a terrific soy latte, and community fellowship at Auckland’s Lifewise Merge Cafe on Karangahape (‘K’) Road. Lifewise is an Auckland-based community and social development agency that works on issues such as child abuse, domestic violence, addictions, disabilities, poverty, and homelessness. They provide direct services and also lead advocacy activities. One of their current advocacy campaigns is to urge the New Zealand government to change the age of ‘aging out’ of foster care. Currently, foster care ends on a young person’s 17th birthday; Lifewise is advocating that age to be increased to 21. They have ample evidence to show that this policy change would help many young people avoid ending up living on the streets.

Lifewise operated a soup kitchen for homeless people in Auckland since 1885. By the early part of this century they were serving over 40,000 meals a year. They realized that their soup kitchen was effectively maintaining rather than solving the issue of homelessness. So in late 2012 they closed the soup kitchen and opened the Merge Cafe on K-Road. The Merge Cafe is one of the few community cafes in the world. They say this of the cafe:

“The café aims to support Lifewise’s one-stop-shop approach to tackling homelessness by connecting patrons with wrap around support services that would in turn provide pathways out of homelessness. Secondly, the café aims to provide both the homeless and the housed alike, the opportunity to enjoy meals alongside each other, in an environment that embraced choice, dignity and respect.”

From what I saw, heard, and experienced there yesterday, the Merge Cafe is a success on all these fronts. They have tables set up to be longer community tables, not the typical isolating small tables. I sat next to a Maori middle-aged man, who told me that he had become homeless at age 16 when he ran away from an abusive home in a rural part of the North Island. He then became involved with a gang–“They gave me a sense of family that I didn’t have growing up”–but through outreach from Lifewise workers he got a “real job” and an apartment ten years ago. “I come back here to this cafe because it’s friendly and I remember what it’s like to be homeless.”

IMG_5777The cafe had a cozy corner ‘book nook’ lined with bookshelves full of paperback books and magazines to read in their comfy-looking chairs. A hot lunch consisting of an entree and a vegetable and roll cost $4 NZ ($2.50 US). The cafe was full of people eating and talking and seeming to be from a cross-spectrum of race/ethnicities, and socio-economic levels. People in the all black business suits so common in New Zealand. People in ‘high-viz’ orange vests of the road crews taking their lunch breaks. Flamboyant, paint-splattered artist-types. Jeans-wearing ‘suspiciously social worker-looking’ but laid back staff mingling around. And many familiar faces of the many rough sleepers I’ve seen around downtown Auckland.

The community cafe. What a great concept. Perhaps we should try to create one in the University District in Seattle? A worthwhile Kiwi can-do spirit souvenir to pack in my suitcase and take back home.

Study Abroad: The Evidence

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Signpost near the Waiheke Island(New Zealand) ferry landing. Photo credit: Josephine Ensign/2015

Until recently, the effects of study abroad experience on college students were mainly anecdotal in nature—more in the form of personal testimonials from students about what they gained through the experience: “Such a blast! Best bar scene ever and their drinking age is 18–how cool is that?!” and “Did you bungy jump yet off the Kawarau Bridge in Queenstown?” to the more serious “It opened my eyes to the way Americans are perceived in other countries.” But parents, university administrators, and funding agencies increasingly want hard evidence on the cost-benefits of study abroad experiences.

The number of U.S. students studying abroad has more than doubled in the past decade. During the 2013/14 academic year (latest stats available), 289,408 students studied abroad for at least a month for academic credit. (Source: Opening Doors, an initiative of the Institute of International Education.) The Institute of International Education recently launched the Generation Study Abroad campaign to double the number of U.S. university students who study abroad by the end of the decade. The campaign also aims to increase the diversity in race/ethnicity, academic disciplines, destinations (the UK and European countries are the vast favorites), and gender. Racial/ethnic minority students, first-generation college students, and STEM majors are underrepresented in study abroad programs. In addition, 65% of study abroad students from the U.S. are female. Are young women more adventuresome somehow?

Here are some intriguing findings from recent studies on the benefits of study abroad programs. Controlling for prior GPA, credit-taking, and SAT scores, a student who studies abroad has a 10% greater chance of graduating in four years than a student who does not. Why would that be, I wonder? It does run counter to what many parents–and even some academic advisors–worry about with study abroad, that it will complicate a student’s credit requirements and therefore delay their graduation. In my own case with a ‘junior year’ study abroad experience, the summer semester’s worth of credit allowed me to graduate a year early. Perhaps through study abroad experiences, students see the value in completing their undergraduate degrees as quickly as possible and getting on with the rest of their lives.

Study abroad experience has been shown to increase students’ self-reported cultural sensitivity, self-confidence/adaptability in dealing with complex, unfamiliar living/working/studying conditions, and knowledge of world geography. The American Association of Colleges and Universities identify intercultural understanding as an essential learning outcome for contemporary university liberal arts education. Employers and graduate school admissions committees place value on prior international study abroad and other international experiences (such as volunteering). For health professions students, study abroad experiences would seem to be ideal for helping to increase cultural knowledge/humility, as well as perspective (and humility!) on the failings of our U.S. healthcare system.

Before our study abroad program started this summer, I asked our current group of twenty-two university students who are here in New Zealand studying community health, to write down at least four personal goals they have for themselves. While a month is not a lot of time for a study abroad experience, it can be impactful, plus I have found it is more accessible to a broader demographic of students who otherwise might not get to have a study abroad experience.

We have an amazing and quite diverse group, many of whom are in (or going into) health professions education, including nursing, social work, medical anthropology, global health, pre-med, and pre-physical therapy. Here (paraphrased to protect identities) are some of what they wrote/shared with me in terms of their goals for this study abroad experience: “To find my place as a global citizen.” “To be able to problem-solve bravely and maturely.” “To learn new ways to manage my stress.” “To let the fire in my heart truly burn for global health.” “To get the chance to slow down and really reflect on where I have been and where I want to be in the future.” “To be able to practice cultural humility and greater global awareness.” “To push my boundaries and push myself outside my comfort zone; deal with difficulties in a mature manner.” And finally, from one of our many ‘first time out of the U.S.’ students, “I hope to have culture shock and awkward moments where my ‘Americanism’ shows.”

If our students accomplish even a few of these personal goals during our study abroad program, I will consider it a grand success.

Resources:

Gone South

Cabin at Camp Hanover, Mechanicsville, VA
Cabin at Camp Hanover in Virginia

For many years now I have sought ways to reconcile with my Southern roots. My white Southern roots. I find it painful to re-read my journals and stumble across blatantly and unselfconsciously racist entries. But I am done with white guilt, as I see that only perpetuates white privilege narcissism. In the words of poet, psychotherapist, and anti-oppression trainer Leticia Nieto, “refuse to re-use recycled guilt.” (From Beyond Inclusion, Beyond Empowerment, Cuetzpalin Publishing, 2014, p 55.)

I am reminded of a powerful quote from one of my favorite authors, William Maxwell (Time Will Darken It, Harper and Row, 1948): ” The present with its unsolved personal relationships and complex problems seldom intrudes upon the past, but when it does, the objects under glass, the framed handwriting of dead men, the rotting silk and corroded metal all are quickened, for a tiny fraction of time and to an almost imperceptible degree, by life.”

And I am reminded of an essay I wrote entitled ‘Gone South’ (Silk Road: A Literary Crossroads, 6.1, 2011, pp8-40), in which I addressed the intrusion of the past that is part of what it means to be Southern. Here are a few excerpts from that piece that I find relevant to our very un-post-racial reality. Of note, I grew up on land that had been taken from the Pamunkey Indians (of Pocahontas fame), which just this week received federal recognition (see The Washington Post article by Joe Heim “A renowned Virginia Indian tribe finally wins federal recognition,” 7-2-15).

I was born and raised on 600 acres in coastal Virginia that was the first racially integrated children’s summer camp in the South. In 1957 my Presbyterian minister father was recruited from his North Carolina church to open and run Camp Hanover. He presided over each solemn opening and closing campfire deep in the nighttime woods, reciting the poem, “Kneel always when you light a fire, kneel reverently and grateful be for God’s unfailing charity.” As he lit the fire, a circle of restless faces gathered around. The faces of the white children glowed in the firelight, while those of the black children stayed hidden.

Our land near Cold Harbor had witnessed the bloodiest battles in the Civil War. Two battles that were two years apart; soldiers on both sides in the last battle unearthed decomposing bodies from the previous battle as they dug trenches. The grounds of Camp were strewn with their bullets, musket balls, and deep earthworks. From an earlier time, the Pamunkey Indians had scattered white quartz arrowheads. My mother collected arrowheads and bullets along the road. She taught me to search for them. (…)

One late summer day in 1970 I was riding in our VW bug, my mother driving on back roads from the Richmond airport. I was ten, sitting in the backseat reading a book, vaguely registering the Virginia countryside and farms we were passing, when she slammed on the brakes.

“Damn!”

I never heard my mother curse, so I looked up quickly.

“What?” I asked.

“Keep your head down and stay quiet,” she said, adding more softly as she turned off the engine, “It’ll be OK.”

I could see her leaning forward, both hands tightly clutching the top of the steering wheel. I slumped down in the seat while quickly peering out the side window to see what had stopped us, to see what would be OK—to see what she didn’t want me to see. I figured it was a bad car accident.

It was approaching dusk, the witching hour for the waning sun. The field next to us glowed golden, with large rectangular hay bales strewn about the field of wheat stalk stubble. Hovering over the field, suspended in the thick damp evening air were shining motes of hay bits, effervescent like Fourth-of-July sparklers. With our car engine turned off, the sound of cicadas and crickets became a curtain of white noise, as mesmerizing as the floating hay.

“Evening, ma’am. Don’t mean no trouble. Gotta stop you here awhile. There’s a meeting passing through, that’s all.”

The man’s voice, polite, official sounding, with crisp words stuck in a slow southern drawl, echoed through our open window. I looked between the seats and saw a spotless white-gloved hand cupped over the doorsill. Behind that was blazing white with a thin, trickling, blood red cross. Above the cross was a white mask and pale thin lips moving within an elliptical cutout area. From the words spoken and the weight of the voice, I expected to see the blue uniform of a policeman. When I first saw the white mask, I had to remind myself it wasn’t Halloween.

As the man moved away, I looked out the front windshield to see where he was going. Up ahead, perhaps fifty feet away, was a swarm of ghostly pointed-hat masked figures swirling around a huge bonfire. It took a moment for me to see that inside the bonfire was a ten-foot dark wooden cross.

“What’s that and why are they wearing those weird costumes?” I asked.

“Shhhhh—I’ll tell you later. Stay down and stay quiet!”

Absorbing the fear in my mother’s voice, I sank deeper in the seat, but moved over in the middle so I could see out the front windshield at the fire and the figures. Several of the white-clad men reached into the fire with long wooden sticks and withdrew flaming torches. Then en masse, with fluid amoeboid movement, the group came toward us, sucking in lone figures as it streamed forward. I heard deep-voiced chanting, words indecipherable as a foreign language. They grew louder, surrounding our car, lighting the inside with their glowing whiteness and lit torches, gently rocking the car as they brushed past it, moving across the road, and thinning to double file down a dirt path. The comforting familiar smell of wood smoke followed them.

I didn’t hear my mother start the car. We were speeding away, screeching around bends in the road. Reflected in the rearview mirror, I saw my mother’s face set hard as stone, etched with the fierce anger I seldom saw. I was more afraid of her anger than I’d been of the men we’d seen. I stayed quiet, bracing myself for the rough ride. When we got home she disappeared into her bedroom, talking quietly with my father—so quietly I couldn’t make out what they were saying, even with my ear pressed against the rough stucco wall between our bedrooms.

At the dinner table that night, my father told me we’d been in the middle of a Klu Klux Klan meeting. “They’re racist white men who wear those costumes to look like ghosts of Confederate soldiers to scare black people—and to scare white people who don’t agree with them— like it scared your mother.”

As I slowly chewed a mouthful of food, I considered this information. The ghostly man who had stopped us seemed polite, a Southern gentleman. Being in the midst of the KKK meeting had been exotic, dreamlike, seductive—almost beautiful. I knew that what I had seen—the way I had seen it—was not something to discuss. I swallowed the dissonance between my mother’s reaction and my own experience of the encounter.

The dissonance remains.

The landscape of my childhood is a landscape of half-buried violence, covered with violets, punctuated by deep, abandoned wells. The roads leading back to it are as twisted as the country roads I grew up on. Within the accretive layers of nostalgia, lie the sludge of orange dust tasting of blood. I fear—and yearn for—the complexity, the offbeat rhythm of the South that formed me.