The Roots of Social Justice: It Starts Here

IMG_0335Poet, dramatist, psychotherapist, and anti-oppression trainer Leticia Nieto, who teaches at Saint Martin’s University near Olympia, Washington, uses a photograph of a tree to represent core power, grounding, and personhood, as she puts it “who we really are when all the layers of rigid roles are stripped away.” The photograph she uses is of a leafless tree with gnarled limbs and trunk in the distinct shape of a human body.

I had the good fortune of attending her workshop titled “Social Justice Through Interpersonal Liberation: Strategic Interventions for Anti-Oppression” at Seattle University’s wonderful Search for Meaning Book Festival at the end of February. I’ve subsequently bought and read her book (with co-authors Margot F. Boyer, Liz Goodwin, Garth R. Johnson, and Laurel Collier Smith), Beyond Inclusion, Beyond Empowerment: A Developmental Strategy to Liberate Everyone (Olympia, WA: Cuetzpalin Publishing). Although it has a fairly heady and pie-in-the-sky subtitle, it is an excellent book. I’ve worked my way through the book, revisited my notes from her workshop, and thought about what it all means for me. I’ve also spent time searching for my own photograph of a tree that represents my own life, grounding, personhood. I considered using a photo I took in New Zealand of the grand Tane Mahuta, an old growth giant kauri tree on the North Island that is upwards of 2,500 years old. That was when I was feeling a bit grandiose. As much as I love that tree and New Zealand, those are not my roots.

My roots, my ‘personhood’ tree is this old Black Oak tree still growing in the leafy green woods of Camp Hanover, my childhood home. This particular oak tree is growing beside on old family graveyard–a family I am not related to as far as I know. The roots of this tree are in complex territory, territory I am still wrestling with in terms of my own social justice and anti-oppression work. Here are a few excerpts from the chapter “First Families” in my forthcoming medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (Berkeley: She Writes Press, August 2016)–excerpts that describe some of this territory:

“The land I grew up on near Cold Harbor [Virginia] had been the site of the bloodiest battles in the Civil War. The two battles were two years apart; soldiers on both sides in the last battle unearthed decomposing bodies from the previous battle as they dug trenches. Our land was strewn with Civil War bullets, musket balls, deep earthworks, and mounded graves. Long before, the Pamunkey Indians had scattered the land with white quartz arrowheads.(…) [There was] as family burial site. leaf-strewn mounds of earth bumped together in a line like the cedar logs on the corduroy road. The site was on a bluff overlooking a ravine cascading down to a small stream. Most of the graves had carved gray headstones: Robert Anderson born March 10, 1792, died July 26, 1853: William Nelson Anderson born February 16, 1837, died May 15, 1851; and, Nancy Peasley Anderson born April 18, 1833, died July 15, 1834. Nancy’s grave was short, but there was an even shorter grave next to it of another Nancy, “infant granddaughter” Nancy Julia Elizabeth with no dates given. A few feet away were six or so unmarked graves, which my mother said were those of Negro slaves. These couldn’t have been content, but I didn’t see their ghosts back then. It was as if they had never existed.”

Place-based Health and Well-being

P1010527If 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

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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:IMG_6708

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‘The Ineffable Gardener and the Developed Seed” 2013, Stainless steel modules, by Lois Cacchini.
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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. IMG_6715

Down and Out in L.A.

IMG_6660Los Angeles, what with its population of over 40,000 people who are homeless and with the nation’s largest concentration of chronic homelessness, is an interesting (and distressing) city to live in. Or to visit. Unless you limit yourself to staying within the sanitized realms of either Disneyland or La-la Hollywood-land.

I was in downtown L.A. for four days recently to attend a national writers conference, but also to see if I could get some sort of context to the problem of homelessness in this giant car-centric sprawl of city–a city like no other. Not being from Los Angeles, it is difficult to decipher what is real and what is just another stage set. Where else would Don Draper (Jon Hamm) of Mad Men saunter through a writers conference and serve as guest editor for a literary magazine’s special edition on advertising writing? (Yes, this really happened, and yes, he is even more handsome in person.) And where else would car crash scenes complete with dazed people staggering around with bloody heads happen right outside one’s hotel? (Yes, this really happened as I was trying to walk from my hotel to an art museum–I almost stepped in to help out with the human carnage before I realized it was actually a stage set.)

On my first day in L.A. I noticed these curious ‘private property’ bronze plaques all over the sidewalks. They basically say, “Move along all you tempest-tossed tired and homeless. Move along. You don’t belong here.”

 

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And these homeless- deterring benches at bus stops. Although–look closely–this one comes with its own food pantry. A man pushing a shopping cart nearby who stopped to inspect these cans told me that people drop off food for the homeless and that cans of vegetables don’t get picked up very quickly. He happens to like vegetables and took all the cans.IMG_6614 I had arranged to do a site visit at the Homeless Health Care Los AngelesCenter for Harm Reduction in the heart of Skid Row in downtown Los Angeles. The director, Mark Casanova, graciously gave me a tour of the facility and talked with me about their work. I’ve visited the Insite safe injection center in Vancouver, BC, so I thought I knew what to expect. Insite is North America’s first and only legally-sanctioned safe injection site and syringe (‘needle’) exchange, although several cities in the U.S.–including my hometown of Seattle–are considering opening one to help address the current heroin epidemic. (See Seattle Times article, “Heroin, cocaine users in Seattle may get country’s first safe-use site,’ by Daniel Beekman, April 4, 2016 for more information.)

 

IMG_6656Visiting the L.A. Center for Harm Reduction with Casanova while it was in operation was an eye-opening experience for me even though I have long been ‘sold’ on the concept and practice of harm reduction: treat people in a non-judgemental and respectful manner and work beside them to find ways to minimize harm to themselves and to other people. From a public health perspective we know that this approach works to save lives and protect everyone’s health.

The eye-opening part was mainly the sheer scale of the need for services such as those provided by the Center for Harm Reduction. They have a syringe exchange that must be one of the largest in North America in terms of quantity of ‘needles’ exchanged. They serve an average of 145 people per day. They also have an on-site wound care clinic and soon will add an on-site drug treatment program. And they have a very successful overdose prevention program where they train clients in the proper use of Naloxone (also known as ‘Narcan’), a non-addicting prescription drug that temporarily blocks and reverses the effects of opioids (prescription opioid pain medications, as well as heroin). Naloxone is available in either an injectable form or a nasal spray. So far, the Center for Harm Reduction, through their own on-site staff and through their street-based program, have prevented over 400 overdose deaths. Here is a photo of the current map showing their overdose reversals. Remember, one of these lives saved could have been your daughter, son, friend, etc.

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Notice the sign in the photo below, asking clients to report police harassment, especially in terms of confiscation of either their syringes or Naloxone/Narcan. Los Angeles has a problem with criminalizing homelessness. Not just with bizarre ‘Private Property’ bronze sidewalk signs and with arrests for and confiscation of drug paraphernalia,  but also with a limitation on the ‘size’ of homeless rough sleepers’ personal belongings. The day before I toured the Center for Harm Reduction, L.A. City Council had just passed a resolution limiting the rough sleepers to whatever personal items (including tents, blankets, sleeping bags, clothing, and food) to what can fit into a 60 gallon container. They say the rest will be confiscated and destroyed. IMG_6618

On a much happier, up with people note, I was impressed by the fact that the Center for Harm Reduction has a companion Healing, Arts and Wellness program next door where they provide space for arts and writing programs, karaoke, a lending library, yoga, acupuncture and cranio-sacral treatment, Zumba fitness classes, and life-skills training. Here are some of my photographs of this very health-promoting space and artwork by participants. Thank you Mark Casanova and all the wonderful staff of Homeless Health Care Los Angeles for all the important work you do.

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Home is…

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Community blue tarp tapestry/ Soul Stories project. Photo credit: Josephine Ensign, 2016

Home-less-ness. Un-homed. Being without “a fixed, regular, and adequate nighttime residence.” 

Where did you sleep last night? Was it in a warm, dry, and safe place?

If you were asked to summarize the essential meaning of home to you in one word or in a brief phrase, what would it be?

As human beings we have to have rest–and sleep–in order to not only thrive, but survive. Sleep is the ultimate letting go and trusting that we will not be disturbed, that we will be okay until we awaken. The trust we have through undisturbed sleep generates hope.

What does it mean to be homeless when home was never a safe place? In such cases, it is not possible for young people to ‘runaway’ from home; they can only run towards home.

Housing, ‘home-ing,’ is a form of health care. The people at the National Health Care for the Homeless Council summarize this connection with the following:

  • “Poor health (illness, injury and/or disability) can cause homelessness when people have insufficient income to afford housing. This may be the result of being unable to work or becoming bankrupted by medical bills.
  • Living on the street or in homeless shelters exacerbates existing health problems and causes new ones. Chronic diseases, such as hypertension, asthma, diabetes, mental health problems and other ongoing conditions, are difficult to manage under stressful circumstances and may worsen. Acute problems such as infections, injuries, and pneumonia are difficult to heal when there is no place to rest and recuperate.
  • Living on the street or in shelters also brings the risk of communicable disease (such as STDs or TB) and violence (physical, sexual, and mental) because of crowded living conditions and the lack of privacy or security. Medications to manage health conditions are often stolen, lost, or compromised due to rain, heat, or other factors.”

For those of us fortunate enough to be currently housed and ‘homed’ in a ‘fixed, regular, and adequate [and safe] nighttime residence’–for those of us who are able to have adequate, safe, undisturbed, restorative-of-hope sleep–let us all remember (or imagine if we’ve never experienced it) what it is like for people who go without these essential human needs. And let us use our rest, our trust, our hope to fix this ‘wicked problem’ of homelessness.

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Notes:

  • The blue tarp tapestry shown in this photo is from my Soul Stories project, and specifically from the ‘Way Out; Way Home’ installation art (in progress). I ask people who view/participate in this installation to contemplate the meaning of home for them. They then are invited to write or draw the word or phase on a strip of paper, the strips are then added to the blue trap tapestry wallhanging weaving.
  • The connection between sleep and trust and hope was inspired by my current research for the Soul Stories project on the role of narrative in health and healing in the context of homeless. Specifically, this concept comes from anthropologist Hirokazu Miyazaki’s essay/chapter, “Hope in the Gift–Hope in Sleep” in Anthropology and Philosophy: Dialogues in Trust and Hope, edited by Sune Liisberg, Esther Oluffa Pedersen, and Anne Line Dalsgard, (New York: Berghahn Books, 2015).
  • I want to acknowledge the generous support of the University of Washington Simpson Center for the Humanities and the National Endowment for the Humanities for funding support for my Soul Stories public scholarship digital humanities project.

Homelessness Visible: A Photo Essay

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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.

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‘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.

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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.

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

Endurance Test

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“No Resilience Here” mixed media, 2015, Josephine Ensign

What helps us—as health care providers, as caregivers, as people, as communities— endure the various traumas and sufferings we’re exposed to indirectly and that we experience ourselves?

Resilience is something that is often cited as an answer to this question. Resilience is a term that has been adapted from engineering to describe the ability of a substance, such as a metal, to return to its previous state after being stressed—the substance is able to bounce back, to return to steady state, to normal. The American Psychological Association definition of resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat.” Resilience is sometimes referred to as ‘good survival.’

Over the past several decades there has been an explosion of research on resilience, mainly focusing on individual risk and protective factors. The main protective factors are, not surprisingly: 1) the formation of a firm, secure attachment to a parent or caretaker figure within the first few years of life; 2) prosocial behaviors and personality traits, such as empathy, a positive attitude, capacity for forgiveness, and ability to ‘play well with others’; and 3) a sense of personal agency, of being able to act, to do something positive both in the midst and the wake of trauma. The main risk factors are, not surprisingly, the opposite of the protective factors.

Most research on resilience has focused on the individual, is Western-centric, and has increasingly become biologically reductionist, narrowing in on the epigenetics of trauma and resilience, finding individuals and entire communities of people with ‘short alleles’ and DNA methylation—genetic markers of increased vulnerability to the adverse effects of trauma. That these are most often individuals and communities already marginalized by poverty and racism and other socially-constructed vulnerabilities, serves to further label and pathologize people and communities. It marks them as damaged goods. As irredeemably, permanently damaged goods. It typically ignores the mounting research evidence indicating that such epigenetic damage is largely reversible and preventable with appropriate life experiences—with access to appropriate life experiences, including effective therapeutic interventions.

Resilience-building interventions include cognitive-behavioral psychotherapy; therapies focused on building the capacity for empathy and forgiveness; narrative storytelling and other meaning-making therapies; and therapies aimed at increasing social support—social support that includes social touch—the human version of primate grooming. Good touch: a handshake, a peck on the cheek, or a hug in greeting; a hand brushing a shoulder in sympathy; sitting close to a stranger on a bus; washing the feet of people who are homeless, people who are rarely touched in a good way.

This all sounds good, but resilience irritates me. The whole saccharine notion that the human body, the human psyche, and even entire communities can be like heated metal—stressed and stretched but not broken—that they can bounce back, return to steady state, and perhaps be stronger and wiser for the experience?  Certainly, I believe that strength-based research and interventions are an important and sizeable improvement over our traditional deficit models so prevalent within health and social services. But resilience has its dark side.

Resilience tends to glorify trauma, and contributes to an addiction to pain and to suffering: What doesn’t kill you makes you stronger. Be the hero of your own life. Cancer saved my life, made me a better person. And Hemingway’s “The world breaks everyone, and afterward, some are strong at the broken places.” It glosses over the fact that trauma and resilience are not equal opportunity affairs, that some people (women, children, people with various disabilities, non-whites, and gender nonconforming people), and some communities (marginalized by homelessness, poverty, racism, and the effects of colonization) are much more likely to be exposed to traumas in the first place, and they have fewer resources to weather and recover from the traumas. It ignores the larger structural inequities, as well as the stigmatizing narratives we place on certain people, communities, and entire impoverished countries. As physician, anthropologist and global health champion Paul Farmer reminds us, “The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise.” (p 288)

Trauma never happens in isolation, even if it is a one-time trauma that occurs to one individual, trauma happens within the context of a particular family, community, cultural, social, and time period. An individual trauma ripples outwards as well as inwards. Suffering from trauma is always a social process; recovering from trauma is always a social process. If suffering is a universal yet unequal human experience, being able to tell and listen to illness and trauma narratives matters. But it doesn’t stop there. Physician, anthropologist, and expert on illness narratives Arthur Kleinman admonishes us that it is the moral and emotional cores of these experiences that matter much more, including the cores of social suffering that especially affect marginalized people.

Kleinman also encourages us to ask the question, What helps us endure? “And I mean by endure withstand, live through, put up with, and suffer. I do not mean the currently fashionable and superficially optimistic idea of ‘resilience’ as denoting a return to robust health and happiness. Those who have struggled in the darkness of their own pain or loss, or that of patients or loved ones, know that these experiences, even when left behind, leave traces that may only be remembered viscerally but shape their lives beyond.” (p 119)

Note: This is an excerpt from a work-in-progress, Soul Stories, a collection of essays on the role of narrative in health and healing.

Sources:

Paul Farmer. ‘On suffering and structural violence: a view from below.’ In: Violence in War and Peace. Edited by Nancy Scheper-Hughes and Philippe Bourgois. (New York)/ Blackwell Publishing (2004). pp 281-289.

Arthur Kleinman. “The art of medicine: how we endure.” The Lancet. January 11, 2014. Vol 383. pp 119-120.

 

Crack Houses and Mass Incarceration

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Rooming house in Jackson Ward, Richmond, Virginia. Photo credit: Josephine Ensign/1988

The deeply disturbing underbelly of the American life many of us have the mixed-blessing privilege of not having to confront: the racist premises of and fallout from our War on Drugs.

The War on Drugs was begun by President Reagan in 1982, and was continued by both Bush administrations, as well as by President Clinton in between the two Bush presidencies. Remember all the crack houses, crack babies, crack crimes, and Welfare Queens that were invoked to stoke the fervor and the funding for the War on Drugs?

As Michelle Alexander points out in her excellent book The New Jim Crow: Mass Incarceration in the Age of Colorblindness (The New Press, 2011), President Reagan began the War on Drugs before crack cocaine was introduced into impoverished, mainly African American inner-city neighborhoods as a ‘cheap high’ substitute for the high-priced White Collar cocaine. All of the ensuing efforts to get ‘tough on crime’ and ‘one strike–you’re out’ have resulted in the U.S. now having highest rate of incarceration in the world. We also have the highest proportion of our racial and ethnic minorities incarcerated. In fact, we have a larger percentage of our black population imprisoned than did South Africa under the height of Apartheid.

The War on Drugs hasn’t made us any safer, as various politicians have tried to make us believe over the past thirty years. It has made us sicker in body, mind, and soul–all of us. It has contributed to a worsening of health inequities since incarceration leads to a never-ending system of debt, to permanent disenfranchisement by taking away people’s voting rights, and of making it almost impossible for people to find jobs and housing once they are released from prison. Not to mention the negative health effects of incarceration on families. I have worked in prisons and in juvenile detention and knew about many of these issues. But I had not really thought of it as a continuation of slavery, Black Codes/ Jim Crow until I read this book and participated in a University of Washington Teach-In on the topic last week.

Here is one of the more piercing passages of Alexander’s book:

“When the system of mass incarceration collapses (and if history is any guide, it will), historians will undoubtedly look back and marvel that such an extraordinarily comprehensive system of racialized social control existed in the United States. How fascinating, they will likely say, that a drug war was waged almost exclusively against poor people of color–people already trapped in ghettos that lacked jobs and decent schools. They were rounded up by the millions, packed away in prisons, and when released, they were stigmatized for life, denied the right to vote, and ushered into a world of discrimination. Legally barred from employment, housing, and welfare benefits–and saddled with thousands of dollars of debt–these people were shamed and condemned for failing to hold together their families.” p175.

And for an excellent recent report on the public health effects of mass incarceration, take at look at the Vera Institute for Justice’s “On Life Support: Public Health in the Age of Mass Incarceration.

At the end of one of the Teach-In sessions “No Sanctuary: Understanding Historical and Contemporary Intersections of Mass Incarceration, Racism, and Health,” Dr. Alexes Harris stated, “The U.S. has always had an insidious system of social control targeted at those who are racialized and poor,” and then she asked each of us audience members, “How do you perpetuate this system?” On this Presidents Day, what an excellent question to ask ourselves.

Framing Homelessness

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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

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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.

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