What does a swamp possibly have to do with health, homelessness, and community health nursing?
Quite a lot as it turns out. I have spent the past year exploring possible answers to this question, as well as many other “swamp questions” and “swamp lessons.” It has been—and continues to be— a weekly deep-dive radical self-care sort of exercise. At the end of each week, I walk to the closest swamp or swamp-like spot of nature, wherever I am in the world, and I sit, observe, and write reflective entries into my swamp journal.
While I have traveled outside of Seattle fairly frequently and lived part of the past year in the UK, when I am at home I always walk to Yesler Swamp on Union Bay in Lake Washington. The photographs included in this post are from my Yesler Swamp walks over the past few weeks.
My weekly practice of swamp walks has been an important source of grounding for me (yes, pun intended since swamps are, at best, ‘quaking ground’) as I have navigated the interesting murky waters of being a leader of the community-campus Doorway Project. The politics involved with this community health project have been considerable. Subtext. Subterfuge. Unnecessary dramas. Wanting to shout “Bullshit!” in so many meetings I have lost count. Take it all back to the swamp and sit with it and see my way through.
Also, my weekly swamp walks and reflections have helped me wade through the new-to-me experience of dealing with the emotional weightiness of developing empathy with ‘historical figures’ such as “insane paupers,” homeless people I have come to know (at least at some level) through my research and writing of my current book project, Skid Road. Who knew (not me) that homeless people long dead could be just as real and deserving of compassion and empathy as those still living?
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.
And for evidence-based individual ‘self-care’ activities taken to the community health level, New Zealand’s All Right? Campaign using the 5 Ways of Wellbeing: Connect, Be Active, Take Note (Be curious), Keep Learning, and Give.
Entering our fourth and final week of this university study abroad in New Zealand program, “Empowering Healthy Communities,” I continue to reflect on how to incorporate service-learning in an international setting, and how to incorporate it in an ethical and meaningful manner. By service-learning with a community health focus I use Serena Seifer’s definition:
“Service-learning is a structured learning experience that combines community service with preparation and reflection. Students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided, the connection between their service and their academic coursework, and their roles as citizens.”(Seifer SD. 1998. Service-learning: Community-campus partnerships for health professions education. Academic Medicine, 73(3):273-277.)
Within a community health and health professions context, service-learning focuses on student engagement in non-clinically focused service work. Thus, our typical community health nursing clinical rotations are not technically considered service-learning, although the lines can get blurred at times.
In a health systems course I teach for senior nursing students, I have included a service-learning option. Students in my course have concurrently volunteered as emergency youth shelter overnight workers, assisted in food banks, and served as buddies for hospice patients. Through this work they can step out of their ‘learning technical skills’ nursing student roles and begin to make systems-level connections and practice critical thinking skills. It has worked well because I’ve partnered with our wonderful University of Washington Carlson Leadership and Public Service Center. They do all the legwork in establishing and nurturing community partnerships, defining student service-learning placements, and monitoring student progress.
Including service-learning in study abroad university-level programs can make for high impact educational experiences. Studies indicate that inclusion of service-learning in study abroad programs significantly increases students’ sense of connectedness with a wider world community. It also helps students confront their own biases and prejudices, and increases their comfort in working within diverse communities. But those benefits come from well-designed study abroad programs that include pre-departure workshops/readings, embedded critical reflective writing by students with faculty feedback, and debriefing sessions after service-learning activities.
Done poorly, international service-learning can be exploitative and can deepen cultural arrogance and economic disparities. As Sara Grusky points out in her article “International Service-Learning: A Critical Guide from an Impassioned advocate,” most international service-learning study abroad programs from the U.S. are done in poor countries, and can become nothing more than ‘poverty tourism.’ (From the American Behavioral Scientist. 2000. 43: 858-867.)
New Zealand is not a poor country and it continues to rank much higher than the U.S. on many health and wellbeing scales. Yet it suffers from rising socio-economic and health inequities. During our study abroad program we have visited a variety of communities–some have been in higher socio-economic brackets, but most have been within impoverished, multi-ethnic and Maori communities. Before doing any community-based service-learning projects, we’ve first learned about the local and national context, including cultural, political, and socio-economic factors impacting the community. Students learn this through carefully chosen readings, and from talks by community leaders.
My co-leader for this program, Jim Diers, is a social worker and an international consultant on community-led, asset-based development. He has a decade or so experience working with various communities throughout New Zealand. So between his contacts and those of the New Zealand based community-development group, Inspiring Communities, we developed this study abroad program. Jim believes in more upstream thinking, policy-changing work versus direct service. It’s an important point, but I think there is room for both in life and in educating university students for their role as civically-engaged change agents. Students have stated that they are now more interested in knowing about and getting involved with their own ‘home’ communities, and of doing service-learning in the Seattle area.
Here are photographs and brief descriptions of various service-learning activities the students have been involved with during the program. Some of the activities were planned ahead of time and others ‘just happened’ spontaneously. All of them were driven by the community members. They have expanded my notion of what ‘counts’ as international service-learning.
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.
The Institute of International Education, an independent not-for-profit organization focusing on student global mobility. They have a great section on research and evaluation of study abroad programs.
As a teacher, I believe in striving to learn from my mistakes. I also believe in the power of international travel and of service-learning. Done well, they can become life-changing, enriching experiences for students. Done poorly, they feed into the Ugly American tourist syndrome.
What follows is part of my self-reflection on a study abroad program in New Zealand that I helped lead in (our) winter of 2014. My essay, titled “Fossicking the Ten Essentials,” was published June 2015 in Traveler’s Tales/Tales-toGo. I’m about to embark as a leader on a ‘take two’ service-learning study abroad program in New Zealand and hope to have learned from my mistakes. I plan to publish a series of blog posts about our progress (while, of course, protecting student identities).
Fossicking the Ten Essentials
Fossicking: An Australian and New Zealand term for “rummaging” and “prospecting,” and specifically for “picking over the abandoned workings” (of gold, precious stones, and fossils.)
The Ten Essentials: A term coined in the 1930s by The Mountaineers Club in Seattle for a list of necessary equipment to take on hikes. Updated in 2003 to the functional systems approach used as the headings in this essay.
~ ~ ~1. Navigation
Using Google Earth instead of a compass or celestial navigation, my current location is 43.4 degrees South and 170.18 degrees East. High noon. Franz Joseph Glacier, at the foot of snow-capped Aoraki/ Mt. Cook, South Island, New Zealand. I’m sitting at the bottom of a huge rock and ice slide at the terminal face of the glacier where its melt waters run into the Waiho River.
The sun is out and there’s no breeze in this deep canyon dug by the glacier. It’s January 2014, high summer here in the land of the Southern Cross, so it’s warm enough to take off my jacket. There seem to be no bugs—no biting flies—no mosquitoes—and no birds to be seen or heard. Feathery waterfalls are cascading down thousands of feet from the sheer cliffs surrounding the canyon. The smell is elemental, metallic. All surfaces my body touches are gritty, covered with the fine glacial flour that turns the river waters to milk, that turns my skin to alabaster, that crunches lightly between my teeth, tasting of bitter iron.
The rocks at my feet are newly fractured, jagged, split open quartz crystals of dazzling white and pale green. I pick one up and gaze into it like a crystal ball, considering its history—considering my history—and considering how it is we came to meet here at the foot of an ancient glacier. Then I become aware of the sound of rocks skittering down from the top of the pile behind me. I will myself to stay, but I turn so I can keep an eye on the rocks. I’m aware of the folly, knowing I could never run fast enough to escape being buried when the rock and ice pile finally gives way. I’m on the supposedly safe side of the yellow rope barrier put up by now absent park rangers. As the sun heats the valley and the rocks begin to fall more steadily, I decide to walk back out of the canyon.
I retreat from the rock pile because I’m leading a group of fourteen young women, college students from Seattle on a study abroad program. I’m responsible for their health and safety for the three months we’re touring New Zealand. I lead them away from the glacier, back into the primeval temperate rainforest of towering tree ferns and vines. The steady din of cicadas and the occasional tremulant trills of bellbirds and tui envelop us.
When we’ve returned to the forest path, I tell the students I’ll meet them back at the van in a few minutes. I duck down a deserted, quiet side path for a few moments of peace—away from the students’ raw enthusiasm, raucous singing, and selfie-picture-taking in front of every scenic view—including the rock pile of the retreating glacier. As I’ve driven them around the South Island in a mini-van, some have taken to yelling out the van windows “Hey cows!” or “Hey sheep!” to scare the herds and then laugh hysterically. Those are the Biology majors, a fact I find ironic. I was a Biology major thirty-odd years ago. Was I ever that young?
On this study abroad program I’m ostensibly teaching community and environmental health, but what I really want to teach is the value of travel as critical self-discovery. Not the navel-gazing, bathetic sort of self-discovery, but rather the sort that leads to greater knowledge of and tolerance for uncomfortable aspects of ourselves and of people we view as “different” from us. I want to expose the students to the deep satisfaction of getting past being picture-taking tourists, instead, becoming travelers, perhaps even pilgrims walking towards the far horizon to arrive home.
It isn’t working out well. So far, halfway into our trip, it’s more like a case study of how not to lead a study abroad program. We’re traveling around so much it feels like we’re never here, in New Zealand. Staying in ten different cities and villages in as many weeks, passing through and ticking off the have-done-have-been-there bragging list of photo-ops, skydiving, and bungee jumping: I feel more like an adventure tour guide (and an emergency room nurse) than a teacher. It’s not helping that we’re staying in youth hostels full of international backpacking nomads who proudly proclaim they have “done Franz Joseph,” they have “done Milford Sound,” they have “done Rotorua,” as if these are all colonial conquests—places and natives and experiences to be possessed and bragged about. But I signed onto this program late and had little hand in its design, so I’m trying to make the best of it.
As we drive and tour and wander, I ask myself: Do we discover more about ourselves through movement or through rootedness to one place over time?
If, as Lucy R. Lippard contends in her book The Lure of the Land, “space” is passing through coordinates and “place” is pausing to make meaning of the space, does it follow that space is to tourism as place is to travel? And if so, what is essential for the work of transforming space into place, tourism into true travel, into pilgrimage?
Seattle is a boom or bust town. Boom times: The timber/logging industry of its early days. The jumping off point for people drawn to the Klondike Gold Rush in the Yukon. The Boeing surge during WWII. And, since the 1990s and accelerating over the past four or so years, the technology boom with Microsoft and now Amazon leading the way. The bust times in between, including the Boeing Bust of the early 1970s, spurring the famous billboard near the Sea-Tac airport reading, “Will the last person leaving Seattle turn out the lights.”
Since its early days Seattle has been a socially progressive place. King County, which includes the City of Seattle, was formed by the Oregon Territorial legislature in 1852. From the beginning, the King County Commissioners were responsible for such things as constructing and maintaining public buildings, collecting taxes, and supporting ‘indigents, paupers, ill, insane, and homeless people living in the county.’ Today, while there is a robust safety net in our community, it is not strong enough. Homelessness in the Seattle area is increasing, with tent cities sprouting up wherever they can, including along the original Skid Road (Yesler Way) in the shadows of Harborview Medical Center as shown in this photo taken late last fall.
As the bumperstickers at the beginning of this post proclaim: Healthcare is a human right; housing is health care. They were produced by the National Health Care for the Homeless Council, of which I am a member. The Council recently issued this timely and hopefully provocative-in-a-good way justice statement entitled Standing in Solidarity: In Support of the Movement for Social Justice. It reads:
“The National Health Care for the Homeless Council recognizes that the significant health disparities associated with homelessness are part of a much larger pattern of injustice in the United States. Poverty and structural racism too often are perpetuated and upheld by poor public policies and narrow social opinion, leaving millions of men, women, children, and youth unable to achieve their potential for well-being and success. We stand in solidarity with the growing social movements and supportive jurisdictions that seek to correct underlying social and economic inequities. We understand that our work as health care providers is part of a much larger struggle to attain human and civil rights, to include the rights to housing and health care.
Numerous recent events involving police violence and community responses have reawakened the national consciousness around the failures of our public systems. Rather than focusing on sensationalized moments and ignoring the daily traumatic violence experienced by those living in poverty, we ask that media outlets instead continue to highlight the root causes of these incidents—social disinvestment, racism, and the ongoing, profound inequities in opportunities, as evidenced by the following:
Incarceration: The U.S. has the highest rate of incarceration in the world, disproportionately among people of color commonly convicted of nonviolent drug offenses. In 2013, nearly 7 million people were in the adult correctional system (4 million on probation, 1.5 million in prison, 850,000 on parole, and 731,000 in jails). People without homes are routinely criminalized for sleeping or sitting in public spaces, as are people struggling with mental illness and addictions. This leaves millions with criminal records that often preclude employment and housing.
Public policies created current conditions, but the policy-making process can also promote a robust and inclusive society. We call for measures to establish for everyone in our country the rights to health care, housing, and livable incomes. We also call for those in the Health Care for the Homeless community—and others allied with this cause—to continue our work toward public policies that achieve social justice.”
Words, and especially metaphors, fascinate me. They are powerful and oftentimes unexamined. Take cliff for example. The OED definition of cliff is: “a perpendicular or steep face of rock of considerable height.” Cliffs are both dangerous and exhilarating-seductive. Think of the aptly named Heathcliff (Emily Bronte’s in Wuthering Heights that is, not the rather insipid comic-strip cat). Cliffs represent the edge of the known and comfortable world. Cliffs are good places to gain some perspective.
Cliff, as a metaphor in the health policy world, is used in various ways. First, there is the ‘funding cliff,’ and specifically the current ‘primary care funding cliff,’ also called the ‘community health center funding cliff.’ Community Health Centers across the U.S. are facing a potential federal funding cut of up to %70 this coming fall (for a good and brief article on it, see the Commonwealth Fund’s Washington Health Week in Review, “Health Centers Push for Remedy to Avoid the Funding ‘Cliff,” by John Reichard, 11-3-14). The National Association of Community Health Centers has a policy issues website on the primary care funding cliff with more information and links to policy advocacy that individuals and groups can get involved in. And here is the RCHN Community Health Foundation’s infographic on the primary care funding cliff.
I am a big fan of community health centers (CHCs) and have worked at three different CHCs in the Seattle area over a period of fifteen years. They typically have very passionate, social-justice oriented people working for them, and they emphasize the use of interdisciplinary teams. CHCs provide comprehensive community-based health care for over 25 million people living in poverty, people who are homeless, as well as immigrant/refugee, and migrant farm workers in urban and rural areas throughout the U.S. CHCs are far from the ‘perfect’ model of care–they are high professional burnout workplaces and they often have much more ‘heart’ than ‘head’ (as in sometimes struggling with good leadership/administration). But they are as close to perfect that I’ve experienced in our country. Not surprising to me is the fact that one of our earliest models of CHCs was the Frontier Nursing Service, started by nurse midwife Mary Breckinridge in 1925 (and still in existence) to provide primary health care in an impoverished rural area of Kentucky.
But to return to the cliff metaphor, a second and important use of ‘cliff’ in the health policy arena is Dr. Camara Jones‘ ‘Cliff Analogy’ framework for levels of health prevention at a population level. Dr. Jones is a family physician and epidemiologist, and currently Research Director on social determinants of health and equity at the Centers for Disease Control. She distills down and illustrates complex health policy/health systems issues through the use of stories and metaphor–the Gardener’s Tale for levels of racism, and the Cliff Analogy for the social determinants of health and of health equity.
In a recent journal article/commentary, Dr. Jones states, “The social determinants of health equity differ from the social determinants of health. While the social determinants of health are the conditions in which people are born, grow, live, work, and age, the social determinants of equity are systems of power. (…) The social determinants of equity govern the distribution of resources and populations through decision-making structures, practices, norms, and values, and too often operate as social determinants of in-equity by differentially distributing resources and populations.” (“Systems of Power, Axes of Inequity” in Medical Care, October 2014, 52(10): S71-S75). In a graphic depiction of these concepts included in her ‘Cliff Analogy,” she shows that the cliff is not a flat, 2-dimensional cliff (as in the infographic above), but is 3-dimensional–differing in how resources, populations, (and, I would add, even the cliff’s physical contours/environment) are distributed.
So on this official President’s Day in the U.S., or Washington’s Birthday for all federal workers, take some time away from the shoe and cars sales and school holiday to consider what actions you can take to make our communities healthier and more equitable places.