Tag: Community health

In Boom or Bust: Standing in Solidarity

Version 2Seattle 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.

IMG_2490
Homeless encampment near Harborview in downtown Seattle. Photo credit: Josephine Ensign/2014.

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:

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.”

Boots On, For My Father

IMG_1232 - Version 3On Father’s Day, here is a piece I wrote about my father’s last years of life, and his quest to die at home, with his boots on, which he did last fall, despite a whole Southern Gothic region-full of subtext and intrigue. If you haven’t yet read Atul Gawande’s powerful and important book, Being Mortal: Medicine and What Matters in the End (Metropolitan Books, 2014), I highly recommend it. The following essay, “Home Death,” I wrote appeared in the Johns Hopkins Public Health Magazine (Spring 2013).

“Natural death, almost by definition, means something slow, smelly and painful. Even at that, it makes a difference if you can achieve it in your own home and not in a public institution.” ~ George Orwell

In his essay “How the Poor Die,” Eric Arthur Blair (pen name George Orwell) describes his month-long stay in a French public hospital in the winter of 1929. He was treated for pneumonia in a crowded open-ward public hospital, where he observed many indigent patients dying under the indifferent care of “slatternly nurses” and doctors and medical students “… with a seeming lack of any perception that the patients were human beings.” He fled the hospital before being discharged, but the hospital was a probable source of the tuberculosis that would later cause his death, at age 46, in a London public hospital.

Like the majority of people in the U.S., my father would rather not die in a hospital—public or private. Studies consistently indicate that more than 80% of patients wish to avoid hospitalization and intensive care treatment during the terminal phase of an illness. In most cases, hospital deaths are considered to be less than ‘good deaths’ because they are not where patients want to die, combined with the high-cost of hospital end-of-life care.

My father would rather die at home with his boots and gardening gloves on, surrounded by family and trusted caregivers. At eighty-nine years old and suffering from the ravages of advanced congestive heart failure, my father is one of the burgeoning number of the ‘very old’ frail elderly facing end-of-life decisions. And I am one of the even larger number of baby boomers approaching retirement while simultaneously helping care for an elderly family member. My father lives in Virginia; I live across the country in Seattle. Nevertheless, my father appointed me his health care proxy. I naively thought that being a nurse practitioner with an advanced degree in public health would help stack the odds in favor of my father having the home death he desires.

I know what it is like when end-of-life care works well. Four years ago I helped my mother have a relatively peaceful home death in hospice. She was eighty-five years old and died of breast and lung cancer. End-of-life predictions are, of course, much more accurate for patients with cancer than they are for patients with congestive heart failure. I had to intervene with her oncologist to stop the chemotherapy that was clearly doing more harm than good. But I expected that. Oncologists are programmed for aggressive treatment and have a difficult time, as the writer Atul Gawande says, letting go. My mother died six weeks after stopping chemotherapy, and two days after learning that her vote helped turn Virginia for Obama. Hers was a good death.

Although I was able to take time off from my job to help my mother in her final illness, my father was her primary home caregiver. Now, with my father living alone, he is hiring caregivers so he can qualify for home hospice. In the past six weeks he has moved through four different health care settings: acute care teaching hospital, nursing home for physical rehabilitation, back to his private home with visiting nursing, and now with home hospice. Besides Medicare, my father has good supplemental private health insurance, and he has sufficient savings to cover out-of-pocket expenses.

Despite my father’s resources, helping him navigate his final days has been a Kafkaesque nightmare tinged with perverse humor. Having worked within the U.S. health care system as a primary care provider for thirty years, I was prepared for the lack of care coordination across health care settings. I was even prepared for his myriad health care providers misplacing his Advance Medical Directives. I keep a scanned copy with me at all times to e-mail or fax it to whichever health care site he’s currently in. But I wasn’t prepared for April Fools’ Day this year.

For transparency and context I should add that I teach health policy to nursing students at a major academic medical center in Seattle. On April Fools’ Day, a Sunday this year, I was in Seattle preparing notes for my upcoming class presentation on patient-centered care. One of my father’s neighbors in Virginia called to tell me my father had skipped church to go to the emergency department of the nearby teaching hospital. He had been complaining of shortness of breath and not feeling well. It takes something serious for my father to miss church.

When I called the hospital to find out his status, the emergency department clerk told me I needed to tell her my father’s “secret HIPAA patient password” before she could even tell me whether he was in the hospital. She added that they strictly enforce this password because the hospital has so many patients involved in gang shootings and domestic violence. She didn’t change her mind when I pointed out that my father was an eighty-eight year old widower and retired Presbyterian minister who had signed his Advance Medical Directive forms appointing me his health care prox in their hospital administrative offices less than a year ago. She said they had no record of it and they had to treat all patients the same, so my only option was to come to the hospital in person. I did make a notation for my health policy class that this interaction was a good example of the need for improved patient-centered care, as well as for more appropriate use of patient privacy rules.

By the time I got through the hospital gatekeepers to be able to talk to my father, a cardiac surgeon had been called down to the emergency department and had convinced him to sign consent forms for a high-risk, high cost, low-to-no-benefit, quasi-experimental transapical arotic valve replacement. Less than six months post-surgery, my father was back in the same teaching hospital for rapidly accelerating heart failure, and I was flying in from Seattle to advocate transferring him to home hospice.

In its current form, our healthcare system conspires against the possibility of older people having a natural, good death at home. While there are pockets of improvement in terms of fewer hospital deaths for the very old, there are accompanying shifts towards more patients seeing ten or more medical specialists in their last six months of life, greater use of intensive care units, and more patients dying in nursing homes. As with my father’s experience, much of the blame falls on teaching hospitals: tenacious places known for medically aggressive treatment. I get the argument that this aggressiveness is what drives medical innovation and makes U.S. high-tech medical care among the best in the world. But when it comes to the care of the very old, that argument does not hold up—unless the elderly are donating their bodies to medical science before they are dead.

According to many studies (reflected in the Dartmouth Atlas of Health Care data) the number of teaching hospital beds in a region is associated with a higher percentage of hospital deaths without a concomitant improvement in overall population health. If the primary mission of teaching hospitals is to educate our future health care professionals, what is it we are teaching them about death and end-of-life care? Perhaps it would benefit everyone if we who work in academic medical centers remember that our students will soon be taking care of us in our own final days.

Josephine Ensign, MPH ’92, DrPH ‘96, is a nurse and writer who teaches health policy at the University of Washington in Seattle.

Just Like Us

IMG_4517This was the first in my summer reading challenge (with a health humanities/social justice slant): Just Like Us: The True Story of Four Mexican Girls Coming of Age in America, by Helen Thorpe (Scribner, 2009). I ran across this book last month at Denver’s lovely downtown ‘LoDo’ Tattered Cover Bookstore (a highly recommended indie bookstore). I asked the helpful information desk woman to direct me to books by local authors, and this was one she recommended.

I give it a one (sunny peace symbol) out of five–also known as ‘I did not like it.’ While it is generally well written, I found it to be too superficial in its treatment of the complex issue of immigration. At one point in the book, Thorpe likens her struggles to be taken seriously as a journalist (while being known mainly as the wife of the Mayor of Denver) with the Mexican young women’s struggles to assimilate to life in the United States. Really? How did that statement get past the book’s editors? In addition, the author lost credibility to me when she admitted to not speaking or understanding Spanish, when the families of the four girls she highlights in the book are mono-lingual Spanish-speaking.

Watching the Corn Grow: Health Care in America’s Rural Heartland

IMG_4416Rural health care is an important and oftentimes overlooked topic in discussions of health policy. It is also a sorely neglected topic within the education of health professions students. Since all the major academic medical centers in the U.S. are by necessity located in larger urban areas, the course content and clinical rotations for health science students focus on the urban or suburban health care contexts. Also, as a colleague of mine pointed out recently, any health researcher/academic wanting to focus on rural health would be committing career suicide. That reminded me of what an academic advisor told me early in my career–that focusing on the health of people experiencing homelessness was a dead-end career move. News alert: no one in positions of power and privilege (including NIH grant reviewers) really care about health issues of marginalized people. Perhaps my advisor was right, but I’m glad I didn’t listen to her.

Ignore your roots at your own peril! I grew up in rural Virginia, in a house on a dirt road that was connected to a dirt ‘rural route’ road with no name. In a house with no curtains on the windows since the nearest neighbor lived several miles away. In a house surrounded by woods and corn fields. I got my occasional health care from a country doctor in his country clinic with its 1940s-era medical equipment. Not unlike many young people who grow up in more isolated rural areas, I could not wait for the day I could ‘legally’ move to a city and never look back at what I saw as the stiflingly -limited scope of rural living. Backwards and bucolic. ‘Watching the corn grow,’ as my city friends used to tease me. Rural areas anywhere in the world are, to me, both of these because they are typically socially and politically conservative, as well as being in lovely and peaceful settings.

Imagine my surprise yesterday when I accompanied an interprofessional health sciences rural health course student field trip to the rural hinterlands of Eastern Washington. I try to challenge myself to go outside my comfort zone on occasion, and yesterday was one of those times. In the twenty or so years I have lived and worked in Seattle, I have only ventured east of the Cascades (within my state) once before, and that was just barely over ‘the Pass’ in Ellensburg for a public health Medical Spanish intensive course. Yesterday we visited several community health clinics, a public health clinic, and a community ‘critical access’ hospital in the tiny crossroads towns of Mattawa (supposedly an Indian word for “where is it?” population: 4,437 ) and Othello (population: 7,364). These were both dusty, semi-arid, almost desert places where I expected tumbleweeds to blow through town along with Wild-West shootouts.

‘Downtown’ Mattawah, Washington

 

But here, in the middle of this dusty, no-stoplight, tiny town of Mattawa, was this gorgeous state-of-the-art, wrap-around, one-stop shopping, culturally-relevant clinic, Wahluke Family Clinic, part of the Columbia Basin Health Association. The Association’s motto is “Keeping healthy those who feed the world.” The outside/front entrance of the Wahluke Family Clinic:

IMG_4374

And the front desk/lobby/check-in area of the clinic: IMG_4387 (1)

 

A tour of the clinic, which has an amazing array of primary health care services including family medicine (physicians, physician assistants, nurse practitioners, RNs), dental/orthodontics, vision care, behavioral health (mental health and chemical dependency services), diabetic footcare/shoes, pharmacy services (including delivery and a drive-through pharmacy), all under one gorgeous roof, with clean, lovely-decorated facilities throughout, a rooftop, sunny staff lunch/break-room and outdoor patio, a fully-equipped indoor gym for all staff members, and original artwork throughout. It all felt unreal, like, really? is this how primary healthcare can be? and wait! this is part of our safety-net health care system, since they are a community health clinic with federal funding, and serving primarily a Spanish-speaking migrant farm worker and lower-income rural population. Plus, it is out in the middle of nowhere.

Besides the dizzying array of health care services, what most impressed me about this clinic (and its linked clinics in nearby Othello), was the attention to the aesthetics of the patient areas, with use of original artwork, seemingly by Hispanic/Latino artists–such as the one in the first photo included in this post.

In stark contrast, were these patient care hallways (mental health services at the Adams County/Othello Public Health Department–why does public health have to be so perpetually, well, frumpy and unappealing?): IMG_4422

and this (is it really even artwork?) hanging on the walls of the small community hospital in Othello (with 90% of its patients being Latina women giving birth):IMG_4426

 

 

 

 

Although I realize I do not know enough about the health care in these small towns/rural areas, I wonder if the quality/cultural appropriateness of a clinic or hospital’s artwork is a good indicator of the facility’s overall healthcare quality. Perhaps in addition to Dr. Paul Farmer’s two indicators of healthcare quality–gardens and bathrooms–could be added artwork/general aesthetics.

I’m not planning to move back to a rural area anytime soon, but after yesterday’s field trip with health science students, I have a greater appreciation of what well-run community-based primary care services in rural areas can look like.

I am a Nurse, Just a Nurse

11164759_1057759667571978_8700043668876075012_nFor many years, whenever anyone said to me, “Oh! You’re a nurse,” I would correct them and say, “No, I’m a nurse practitioner.” Why? As if identifying myself as a nurse was somehow beneath me? As if being a nurse practitioner meant I wasn’t really a nurse, or I was more than a nurse because I could diagnose and treat medical problems, something nurses can’t do? As if I was too intelligent to be ‘just’ a nurse?

I was not born to be a nurse; I was not called to be a nurse. I didn’t need multiple-choice tests and multiple sessions of career counseling at pivotal junctures in my life to tell me these facts. What with the Myers-Briggs Type Indicator, the Strong Interest Inventory, the Eureka Skills Inventory, and the Holland Personality test results, my career counselor proclaimed, “You don’t have the personality, the interests or skills test results to match nursing.” It seems I was meant to be a writer. Oops. Too late. When she told me this I had already been a nurse/nurse practitioner for over thirty years. Of course, it was my job as a nurse practitioner and nurse educator (and most definitely not as as an unpaid writer) that allowed me to take these expensive tests in the first place.

But oh the places nursing has taken me! If I had it all to do over again, if I didn’t have to worry about being a single mom earlier in my career trying to earn a decent income, if I could choose any of the health professions to ‘become,’ I would choose to be a nurse. I would choose to be the ambivalent, skeptical, social-justice minded, community/public health-focused nurse that I am. Last summer I reflected on where community health nursing has taken me, and I made this short digital storytelling video: “My Story of Community Health Nursing.”  Even though this was my first video, and I see that it is clunky in places, I revisit/re-watch it on occasion to remind myself of who I am, and of why I love to do the work I do–including teaching nursing students and encouraging them to consider becoming a community/public health nurse.

The photo included in this post is a ‘retouched’ photo of a University of Washington School of Nursing promotional placard reading “I am a #huskynurse.” It’s not that I’m opposed to proclaiming myself an over-sized, plump nurse. But I am opposed to being a (branded) nurse. I am an–unqualified– nurse. I am a nurse. I am a community/public health nurse.

Happy National Nurses Week and Happy 195th birthday to Florence Nightingale!

_________________

“Just a Nurse” is used with a nod to the work of Suzanne Gordon, a journalist who writes about/is a longtime advocate for nursing.

Spring Blue(s)

IMG_4065
Photo credit: Josephine Ensign, 2015

Why do spring and depression go together? The seasonality of illness is fascinating and is proof that our environment matters quite a lot to our individual and collective/public health. In temperate regions of the world, injuries and drownings go up in the warmer months, and deaths from influenza and carbon-monoxide poisoning go up in the colder months. These make sense. But when we think of depression and suicide risk, most of us would guess that these peak in the fall and winter months–what with decreased hours of sunlight and the stresses of some of the major holidays. In the U.S., September is National Suicide Prevention Month and October is National Depression Awareness Month, and many news reports continue to falsely link higher rates of depression and suicide with fall and early winter.

Yet studies worldwide find that depression and suicide rates peak in late spring and early summer. High pollen counts, increased hours of sunshine, higher temperatures, and even an increase in thunderstorms (ah–that Shakespearean pathetic fallacy!) have been linked to higher rates of depression and suicide. Within psychology and sociology circles, this seasonal link is theorized to be from the fact that people generally have increased social pressures and interactions in the spring, which can increase stress. (see “The Season of Renewal and Suicide” by Brian Palmer, Slate, 12-7-12).

The most current statistics from the CDC on the leading causes of death in the U.S. (for 2013), list suicide (intentional self-harm) as the tenth leading cause of death, with the total number of deaths by suicide as 41,149. (Suicide is the second leading cause of death for young people ages 15-24 years.) This continues the upward climb of suicide deaths in our country since the start of the Great Recession, with the largest increase being in people 45-64 years of age (peak wage-earning years.) With the possible exception of unintentional injuries, such as motor vehicle accidents, suicide is our most preventable form of mortality. And suicide deaths have serious impacts on the family members, friends, co-workers, and care providers who knew and loved the people who killed themselves. Note: they did not ‘commit’ suicide as is still too commonly used; suicide is not a crime or a sin–it is a preventable travesty. Using the term ‘commit suicide’ adds to the already debilitating stigma of mental illness.

So what are interventions that work to help prevent deaths by suicide?

1) Train healthcare providers to screen for depression, drug/alcohol use, bullying at school (for young people), history of adverse childhood events (especially sexual abuse), and suicidal ideation and attempts. In primary care screening for depression and suicide risk (as well as intimate-partner violence), a standard question is “Do you have access to a firearm?” This screening question seems so obvious, as access to a lethal weapon is an important part of the overall risk assessment. Over half of all deaths by suicide are by firearms. But now in Florida that healthcare screening question is illegal for physicians and nurses to ask their patients. (See James Hamblin’s 8-11-14 article in The Atlantic, “The Question Doctors Can’t Ask.” ) And other (mostly Southern, no surprise) states have similar legislative ‘healthcare gag orders’ pending.)

2) Educate the general public about the warning signs of severe depression, problematic drug/alcohol use, and suicide–and give them the proper tools to be able to intervene effectively. Reinforce the fact that talking about suicide in a supportive way does not encourage suicide (just as talking about sex or drug use with adolescents does not encourage them to have sex and use drugs.) An excellent (free and 24/7) resource is the National Suicide Prevention Hotline at 1-800-273-TALK (8255). They can connect people with local crisis centers and assistance.

3) Implement a community-wide public mental health promotion (and depression/suicide prevention) program. One such model program that is cost-effective and that could be replicated in the U.S., is New Zealand’s All Right? Wellbeing Campaign, a Healthy Christchurch project that is being led by the Mental Health Foundation and the Canterbury District Health Board. As they state, “All Right is a social marketing campaign designed to help us think about our mental health and wellbeing. It’s about helping people realise that they’re not alone, encouraging them to connect with others, and supporting them to boost their wellbeing.” Although targeted at earthquake recovery efforts in the Christchurch area, this public mental health campaign could be most effective at building community resilience before major disasters occur.

My students and I stumbled across the work of the All Right? Wellbeing Campaign while we were in Christchurch last year studying community health. I wrote about it in a series of blog posts, including “New Zealand Postcards: The Allrighties” 2-3-14. Some of our health-focused students ‘brought this home’ to Seattle and started the student-led “What’s Up UW?” community for promoting social and emotional wellbeing.

IMG_4095
From the All Right? Wellbeing Campaign, Christchurch, New Zealand.

 

 

 

New Orleans Bottle Djinn: Stealing Stories?

IMG_2167IMG_2170

New Orleans, Louisiana, French Quarter, May 2014. Part II.

How do people deal with and bear witness to trauma? How have the people of New Orleans collectively chosen to remember Hurricane Katrina?

As I wrote in my previous post “Collective Sites of Memory: New Orleans” (3-28-15), those were some of the questions I was pondering last May as I returned to New Orleans for the first time since Katrina. Having visited–and been disappointed by–the Katrina National Memorial Park in New Orleans, I decided to visit the permanent exhibit “Living with hurricanes: Katrina and beyond” located at the Presbytere Louisiana State Museum in the heart of the French Quarter.

Greeting me in a wildly disorienting way as I entered the main door of the museum building, was the art installation shown in the photos above. Hundreds of ‘floating’ glass bottles with messages curled up inside them, all hanging from the ceiling. Interspersed among the bottles are ghostly blue glass hands, reaching down–or wait! are they reaching up out of the deluge, the person attached to the hand drowning and asking to be rescued? I stood in the middle of the foyer gazing up at the display as the lights surrounding them gyrated from blue to purple to pink to red and back again–trying to figure out which way was up and which was down in this display. Who are the rescuers and the rescued? It felt as if I was simultaneously the rescuer and the rescued—floating in the midst of the primordial sea of life.

The brightly-colored bottle display also reminded me of that uniquely Southern folk art of bottle trees, shown here in a classic black and white photograph by the venerable writer (and WPA photographer) Eudora Welty. The folk belief is that placing bottles on trees away from the main entrance to the house will help to capture and repel ‘bottle genies’/djinn/or ‘haints’—spirits that haunt a place. The bottle trees are thought to protect people and their homes from calamities. Maybe all the pent-up bottle djinn in the New Orleans area had been released by Katrina.

P1000196 - Version 2
House with bottle-trees/Simpson County/1941/ Eudora Welty. From Eudora Welty Photographs, University Press of Mississippi, Jackson, 1989.

I have the habit of always looking at a piece of art before reading the accompanying information placard, which often ‘explains’ or interprets what the artist is aiming for. I like to experience the art before being told what it is I am looking at (or hearing), and how it should make me feel. But after several minutes of standing in the museum’s foyer gazing at the bottles and light show, I read the placard below:

IMG_2173The “Message of Remembrances”  (notice the singular ‘message’ in the title) was next to the official entrance to the Katrina exhibit, with a large sign stating “Resilience.” Oh no,  here we go with the official scripted, up-with-people resilience narrative, I thought, as I entered the darkened room.

‘Resilience’ is an oft-used and ill-used term. ‘Bad things happen to good people, but what doesn’t break you makes you stronger.’ I am highly suspicious of resilience and any context within which resilience is mentioned. I put it in the same category with all those ‘redemptive’ novels according to Oprah: catharsis equals a nauseatingly Hallmark Moment.

But, okay, I will attempt to suspend my critical stance and give this museum exhibit on Katrina an honest chance,  I told myself.

As I snaked my way through the rooms of the exhibit, I found quite a lot to admire in how the curators had chosen to ‘tell the story’ of Katrina. The first few rooms were dark and immersive, showing billowing smoke from one New Orleans building, next to a display of an ax stored in the attic of a ‘mock’ house (an essential home safety precaution that I didn’t know about–many people in Katrina got trapped inside their attics in the rising water and drowned because they couldn’t cut an escape route through their roofs).

Then I entered the second room of the exhibit, filled with separate displays on ‘ordinary heroes’ (what is an extraordinary hero–Wonder Woman?), hospitals, First Responders, seats from the Superdome (fiasco), samples of emergency cans of water from the Red Cross, and MREs (Meals, Ready to Eat that included little bottles of Tabasco hot-sauce). There was a brief and somewhat sanitized display labeled “Race, Class, and Inequality” with a heavily edited quote from then President George W. Bush. This second room was filled with random flashing lights of red, yellow, and that freaky blue again, echoing the bottle display.

There was quite a lot of content on the effects of climate change, environmental degradation, and engineering mistakes that all compounded the devastation of Hurricane Katrina. Audio-recordings of Katrina survivors played on an endless loop. An African American man, a former resident of the most severely affected Ninth Ward had this to say: “The water in the vast area matched the speed of a second hand of a clock—that was the amount of time it took for that water to rise. I don’t remember hearing it before: a sound like a freight train.” I found his first person testimony both eloquent and haunting, and I listened to the loop several times to make sure I wrote down his exact words.

But one section of the Katrina exhibit has continued to bother me. It takes up the most space in the middle-part of the exhibit, being eight or nine panels, sections of the actual walls in a central New Orleans housing project apartment. The walls preserve the ‘wall diary’ of Tommie Elton Mabry, a 53 year old man (shown in photo below in front of his wall diary/ ‘ledger or graffiti’ as he called it–written with a black Sharpie.) Mabry, who had been homeless ‘since Regan was president,’ stayed in a first-floor apartment in the deserted high-rise B.W. Cooper public housing development in downtown New Orleans. Starting the day before Hurricane Katrina hit New Orleans until two months later when he was forced to leave by the housing authority officials (the building has been torn down).

IMG_2203
Tommie Elton Mabry in front of his diary of Katrina written on wall of New Orleans Housing Authority building. Photo: Thomas Neff, November 2005.

What bothers me about this part of the exhibit is the unacknowledged ethical issues, power dynamics, and inherent racism and classism. Mabry’s diary entries are written in about a fourth or fifth grade level, include frequent f-bombs, and many of the entries focus on him getting drunk or nursing a hangover. These all highlight negative stereotypes of homeless people, and especially of African American poor people.

In the photo and in several local newspaper articles (see below), Mabry appears to be proud of the fact that his diary is now on permanent display in a museum. But did anyone bother to ask his permission before they preserved his ‘wall diaries?’ Did anyone consider setting up some sort of appropriate payment–or housing fund– for use of his words?

Tommie Elton Mabry died of a heart attack in 2013, at the age of 58. He was still homeless and couch-surfing at the time of his death.

_______________________________

Resources/related articles and videos:

“After Hurricane Katrina struck, Elton Mabry used writing as a way to survive the storm” by Maria C. Montoya. The Times-Picayune, August 23, 2008.

“The diary of Tommie Elton Mabry” (video). The Times-Picayune, September 1, 2010.

“Hurricane Katrina survivor and chronicler Tommie Mabry dies at 58” by Elizabeth Mullener. The Times-Picayune, February 1, 2013.

“Jungleland: The Lower Ninth Ward in New Orleans gives new meaning to ‘urban growth,” by Nathanial Rich. NYT, March 21, 2012.

 

Collective Sites of Memory: New Orleans

Storm clouds over the Mississippi River, New Orleans. Photo credit: Josephine Ensign/2014
Storm clouds over the Mississippi River, New Orleans. Photo credit: Josephine Ensign/2014

New Orleans, Louisiana, French Quarter, May 2014.

I returned to New Orleans in May 2014 to attend the National Health Care for the Homeless Conference and Policy Symposium. The last time I was in New Orleans was in the summer of 2005, less than a month before Hurricane Katrina tried to return the city to the sea. In Seattle, in the first few years after Katrina, I had taken care of many homeless and near homeless patients who had been displaced by the storm. I knew that most of these patients were among the more than 100,000 former residents of New Orleans who left in the aftermath of Katrina.

Now, almost a decade after the devastating hurricane and the national tragedy of how it was handled, I wondered how the citizens of New Orleans had chosen to remember it. I went back to New Orleans to participate in the conference and policy symposium, but also to track down their Katrina memorials, their collective sites of memory. Hurricane Katrina was, of course, both a natural and a man-made disaster, what with its socially determined patterns of protection and vulnerability based on race, class, and gender–not to mention the effects of environmental degradation and Global Warming. How individuals and communities deal with the aftermath of a large-scale and complex disaster was something I’d been pondering. I had recently visited the Christchurch, New Zealand post-earthquake sites of memory (and written about it in a series of blog posts, the most popular one here).

How do people deal with and bear witness to trauma?

I went in search of the National Katrina Memorial Park. No one, not even the concierge at my mega French Quarter conference hotel had ever heard of this memorial. With hazy directions and a very silly-simplified tourist map from my hotel, I hopped on a streetcar not named Desire and headed up Canal Street towards the Cities of the Dead.

The Katrina National Memorial Park is located at 5050 Canal Street, across the street from some strange Herb import store painted bright green (reminiscent of the Green Pharma’ing of Seattle since our state legalized marijuana). Entering the black wrought-iron gates and reading the first marker/sign greeting me inside, I realized that I had arrived at Potter’s Field, or the ‘City of the Poor and Forsaken Dead’ as I prefer to call it.

Potter's Field Crematory, New Orleans. Photo credit: Josephine Ensign/2014
Potter’s Field/Charity Hospital Cemetery, New Orleans. Photo credit: Josephine Ensign/2014

It is the site of the Charity Hospital Cemetery, on land purchased by Charity Hospital in 1848, and called Potter’s Field in the lingo of the time. “It has historically been used to bury the unclaimed from throughout the city, including the victims of several yellow fever and influenza epidemics,” proclaims the sign. It also contains the ashes of people who “donated their remains to the Louisiana State Anatomical Board for medical education.”

Walking farther into the cemetery, I was greeted by these strange, shiny black marble structures, which another sign identified as the Katrina Memorial mausoleums. They contain the ashes of the dead.

Katrina National Memorial Park, New Orleans. Photo credit: Josephine Ensign/2014
Katrina National Memorial Park, New Orleans. Photo credit: Josephine Ensign/2014

A sign states that the swirling pathways lined with these strange structures is supposed to mimic the shape of the hurricane. It is designed to “create a meditative labyrinth, a healing space for reflection.” The fact that the Katrina mausoleums most strongly echo back to the Nazi concentration camp boxcars for extermination of Jews, Gypsies, disabled, homeless and other ‘undesirables,’ did not make this space–this site of memory–either meditative or healing. Who, I wondered, was responsible for the design of this place?

Ah, of course! I thought, as I read a sign stating that this Katrina Memorial was created by Dr. Frank Minyad, Coroner of Orleans Parish. Dr. Minyard, an OB/GYN physician by training, a white man dubbed “Dr. Jazz” as well as “friend of the police” because of love of both trumpet-playing and covering up controversial ‘accidental’ deaths of black men while in police custody. Dr. Minyard, the self-proclaimed “community servant,” upholder of what he calls “the Palace of Truth,” at the time of Katrina our county’s longest-serving big city elected coroner (and not a forensic pathologist,) and a rather loathsome interviewee in Frontline’s 2011 stark, startling, and effective video episode Postmortum: Death Investigation Crisis in America. I show and discuss this video every spring in my undergraduate nursing health policy course, so I remembered Minyard very well.

As sat on a bench waiting for the Streetcar Not Named Desire back to my French Quarter tourist hotel, I felt sad, empty, and duped. This was not the community/collective site of memory of proper remembrance of the national shame, of “Is this America?” of post Hurricane Katrina that I had come in search of.

Falling Off the Funding Cliff of Good Health

cliff-475661_640Words, 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. Funding-Cliff-Infographic-1And 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.