Tag: Health policy

Teaching Health Politics and Policy in the Time of a Pandemic

Where to begin? For one thing, I will begin by acknowledging that I still have a job, and I have a job that can be done from the “shelter in place” comfort of my own home here in Seattle. These are privileges that I am acutely aware that many others in my neighborhood, city, country, state, and world do not have. These are privileges that homeless people I work with do not have.

I will not complain about having to “pivot” (but oh how I loathe that over-used term right now!) and convert a new health politics/policy course from an in-person class format to completely online within a week’s time. I will not complain that the hastily-added Zoom feature on our course websites is already crashing and our spring quarter has not yet begun.

The course I designed and will be teaching starting next week is a required course for all pre-licensure nursing students in our newly revised curriculum that rolled out this past fall. I have a cohort of about 150 students, a mixture of traditional BSN students and accelerated BSN (ABSN) students–meaning they already have a degree and complete their nursing courses in one academic year. The ABSN students will soon graduate and enter the nursing workforce. Many of them, as well as the BSN students, are already working as nurse techs in hospitals and nursing homes. Since most of them live and work in the Seattle area—the site of our country’s first COVID-19 outbreak and known community spread and mounting death toll along with the insane shortage of basic protective gear like masks—they know first-hand two lessons included in my course syllabus: 1) US healthcare is characterized by excess and deprivation (rich people still getting tummy tucks and facelifts while COVID-19 patients die from lack hospital beds/staff/ventilators), and 2) rationing of healthcare is already a reality even before the COVID-19 pandemic reached the US.

Luckily, I had this same cohort of students last fall quarter in a community/population health course which we now lead with instead of including as an afterthought as most nursing schools still do. As part of that course, I had them complete the excellent (and free!) online training modules on disaster preparedness (include mental health/PTSD in first responders) from the Northwest Center for Public Health Practice. I also had them write a narrative policy paper based on Health Affair‘s “Narrative Matters” series of essays. Many of their papers were excellent and based on current event public health/health policy topics.

For the spring quarter health politics and policy course I will have them work in teams (virtually, of course) of ten students and write and produce 8-10 minute personal policy and advocacy storytelling videos based on current event topics (including the pandemic). These are based loosely on the StoryCenter/Nurstory series of videos, although all of theirs are single person-single story videos. (One of my favorites is “Pride and Prejudice” by Maud Low on reproductive rights.) I am excited to see what they come up with and will–with their permission–share/link to some of their final participatory/narrative policy videos at the end of the quarter.

In yet another surreal moment in the midst of numerous such moments during this time, I am struck with the fact that by writing/thinking about “the end of the quarter” I have the simultaneous realization that—assuming my students and I are still standing (or sitting, or lying) by then—we will all have been even more profoundly and personally touched by this pandemic.

Dorothea Dix and the Trade in Lunacy

Dorothea Dix, Harvard University Houghton Library

Dorothea Dix was a leading US and international mental health reformer. She knew how to wield her quill pen and do her own reporting to advocate for positive changes. We still have a lot to learn from her.

Starting in 1830 with her investigative reporting on the deplorable conditions of inmates at a Cambridge, Massachusetts jail, Dorothea Dix quickly spread her mental health advocacy efforts with inspections of prisons and insane asylums throughout Massachusetts and other states, then internationally to England and Scotland (petitioning Queen Victoria for reforms), France, Italy (petitioning Pope Pius IX), and Turkey (trying unsuccessfully to meet with and petition Florence Nightingale at the end of the Crimean War).

After Dix’s controversial stint as Superintendent of Women Nurses for the Union Army during the American Civil War, she again took up her mental health reform efforts extending them to the Far West, visiting California, up through Oregon, to Washington Territory. Remarking on the natural beauty of Washington, including snow-capped Mt. Rainier, she described in a letter to her British Quaker reform friends, the Rathbones of Liverpool, that she was favorably impressed by the Pacific Northwest’s “humane and liberal” prisons and insane asylums. She attributed their excellence to how newly settled the area was, a newness that allowed for more progressive thinking than in either European or the American East Coast cities.

Dix was involved with political debates raging in England and Scotland where local parishes used the contract system, paying for their insane poor to live and work in private, for-profit insane asylums. Many of the asylum proprietors cut costs and increased their profits by shackling patients inside unheated rooms and depriving them of food and medical care. Known as the “trade in lunacy,” once the truths of the trade were uncovered, the practice was a source of widespread moral outrage and calls for reform.

In America, there were claims that treatment of insane incurable paupers in state-run insane asylums was a more humane approach. Proponents claimed it would save money in the long run, given economies of scale and since patients could avoid being sent to higher-cost jails and prisons.
Early reports from institutions such as the Worcester Insane Asylum claimed high success rates of “curing” patients of their insanity, by citing high patient discharge rates. What they failed to mention were the equally high rates of readmission of these patients to the same or similar institutions within short periods of time. Once forced to face these statistics, proponents of insane asylums, including Dorothea Dix, began to point to “seasonable care,” meaning that successful treatment and cure rates occurred when patients were identified early in their illness and were provided with appropriate treatment at insane asylums. Early in their illness was typically defined as treatment within the first year of onset of their symptoms.

Public and private debates in America were raging as to whether paupers–insane or not–brought on their own plights through immoral acts such as intemperance, specifically in terms of alcohol consumption, and the duty of the state to care for such people. Calvinist work ethics and conceptions of sin and salvation colored these debates. Women with children “out of wedlock” and prostitutes were labeled as sinners and as undeserving poor. Leading reformers such as Dorothea Dix declared that the duty of society was the same whether insanity or destitution resulted from “a life of sin or pure misfortune.”

Sources:

Dorothea Lynde Dix, Asylum, Prison, and Poorhouse: The Writings and Reform Work of Dorothea Dix in Illinois (Carbondale, Ill.: Southern Illinois University Press, 1999).

Thomas J. Brown, Dorothea Dix: New England Reformer, Harvard Historical Studies ; v. 127 (Cambridge, Mass.: Harvard University Press, 1998).
Dix, Asylum, Prison, and Poorhouse.

Legislative Assembly of the Territory of Washington, “An Act Relating to the Support of the Poor.”

Tamonud Modak, Siddharth Sarkar, and Rajesh Sagar, “Dorothea Dix: A Proponent of Humane Treatment of Mentally Ill,” Journal of Mental Health and Human Behaviour 21, no. 1 (2016): 69, https://doi.org/10.4103/0971-8990.182088.

Dorothea Dix, “‘I Tell What I Have Seen’—The Reports of Asylum Reformer Dorothea Dix,” American Journal of Public Health 96, no. 4 (April 1, 2006): 622–24, https://doi.org/10.2105/AJPH.96.4.622.

Dorothea Lynde Dix, The Lady and the President: The Letters of Dorothea Dix & Millard Fillmore (Lexington: University Press of Kentucky, 1975).

On (Homeless) Self Promotion

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Happy 1st birthday to my medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net. There is this upcoming sale of the e-book for all you e-bookish fans.  It has been a fascinating and fun year and it has taken me places I never expected to go.

Leave Things Better Than You Found Them

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Concrete jungle courtyard (when first built in 1947 and now) of the University of Washington Health Sciences.

Leave things better than you found them was a lesson I was taught as a nineteen-year old college student during my study-abroad experience. That, along with celestial and non-celestial navigation, how to sail a 125′ Topsail Schooner, how to survive a Force 9 gale off the coasts of Labrador and Newfoundland, how to identify a multitude of sea creatures—including a 70′ Balaenoptera musculus (blue whale), how to take depth soundings of a Newfoundland fjord while perched in the bow of a tiny dinghy, and how to write and type a scientific report while rolling around on the high seas. Oh yes, and the poetics of sea shanties. All skills and knowledge and experiences that have served me well in life, reinforcing for me that value of experiential, immersion study-abroad programs.

But it is the seemingly trivial lesson of leaving things better than you found them that comes back to me most often, including this past week during the vicissitudes of the latest round of “let’s mess up our U.S. healthcare system even more.”

During my S.E.A Semester study-abroad program, Captain Carl Chase, our taciturn and highly capable and salty leader, sat us all down the first day of our voyage and explained that, in addition to our academic and sailing and galley work for the next six weeks, we were expected to find one thing we could do to do leave the ship in better shape than we had found it. He left it up to us to figure out what to do and then he would provide the materials and guidance necessary to complete our project. My project became the carving of a wooden knob for the battered galley teapot which had lost its knob. I liked to complain about the difficulty prying the top off the teapot and then realized I could—and should—stop complaining and do something to fix the problem.

Whenever I find myself complaining about things, like the ugly weed-filled concrete planters in the main courtyard at work, or the direction our country is going, or the direction the profession of nursing is going, or any of the myriad of issues I care about, I remember Captain Chase and the teapot knob and try to find some achievable improvement I can make.

And I know I am not alone in this effort. For instance, the Canadian nurse writer Tilda Shalof was recently highlighted in the Toronto Star article and accompanying video interview, “Medical Waste Becomes Massive Medical Art Mural.”  As she prepares to retire from her decades working as an ICU nurse, Shalof turned the acres of brightly-colored plastic covers to various medical supplies into a beautiful art mural to adorn the hospital’s walls.

Health Care as Political Weapon

Version 2Access to affordable, quality, basic health care is a basic human right. Basic, as in fundamental and essential. In a civil society, in a democracy, health care should not be used as a political weapon—as it is being used by the current U.S. government administration. Using health care as a political weapon is sick. That it is being used as a weapon by powerful, affluent (mostly men) with the best health care and most comprehensive health insurance in the country—against those of our society who have the least power and resources, is despicable.

Repealing the ACA, which all health policy experts agree has had far-reaching positive effects on our health care system and on millions of people’s access to care, is senseless and mean-spirited.

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For a brilliant critique of the current heartless rhetoric of the leaders of the ACA dismantling, please read Nicholas Kristof’s NYT op-ed piece, “And Jesus Said Unto Paul of Ryan…” (3-16-17).

Why We Need the Homeless

IMG_8941As Phillip Lopate points out, perverse humor and contrariness can help us break through our ingrained ways of thinking, can help us view emotionally charged problems in our world through a more constructive lens. With that in mind, here’s why we need homelessness, why we shouldn’t be trying to end or reduce homelessness at all, but rather encouraging it.

Homelessness is good for individuals because it provides an education in life not available by other means. If you’re young and homeless and have a sense of adventure, you can travel around the country in a Jack Kerouac sort of way, get to see more cities and small towns and different ways of living than you’d ever be able to do if you were not homeless and if you were working full-time to try and stay not homeless. We should encourage homelessness in our young people, as it would increase their civic and geographic literacy and help us avoid the high cost of a college education.

Homelessness is good for our society. First, it is good for the environment because people who are homeless often recycle things. They find discarded aluminum cans and plastic bottles in ditches beside streets and turn them in to recycling places in exchange for money. Homelessness is good for the environment because people who are homeless often leave very small carbon footprints: they usually don’t own cars, or if they do, they can’t afford the gas to drive them so they rely on public transportation, ride bicycles or skateboards (if they are young), or simply walk to where they need to go. They eat leftover food that would otherwise go to waste and have to be carted off in garbage trucks and take up space in land fills. This especially applies to all of those excess Starbucks pastries that have to be thrown away at the end of each day. Homeless people don’t use much electricity, especially if they live outside, and even if they stay in public or church-run shelters, the cost per person of heating or cooling the shelter area is quite cost-effective.

Homelessness is good for the economy because our US market economy is based on winners and losers, the wealthy and the poor: having people who are homeless on our streets—so visibly down and out and poor—reminds us that our economy is working. It reminds us on a personal level that we had better keep working or we will end up like them: homeless. It’s a good moral lesson for our children when they are lazy at school. We can point out a homeless person and say: “See—that’s what you’ll become if you don’t study harder!” Homelessness is good for the economy because, like migrant farm workers, many homeless people do day labor, such as construction or yard work, for very low wages. This enables businesses to turn a higher profit.

Homelessness creates jobs for people, especially jobs in public health and social work, as well as jobs for journalists and researchers who focus on homelessness. Homelessness and poverty support health care providers, teachers, social workers, and other professionals who are incompetent or impaired, and who wouldn’t be tolerated in care settings for affluent persons. People who are homeless—along with other poor people—help support medical innovation, since many of them serve as patients and research subjects in academic medical centers. Of course, these medical innovations mainly benefit affluent people who can afford health insurance to cover the cost of such innovations.

Please support homelessness. Our country needs more of it.

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From my medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (Berkeley: She Writes Press, August 2016).

Note: For this piece I was influenced by Herbert Gans’s article “The Positive Functions of Poverty” in The American Journal of Sociology (Vol. 78, No. 2, September 1972) and by Joel John Robert’s article “Ten Things We Can Do to Perpetuate Homelessness,” published in the Los Angeles Times (July 19, 2003).

Evicted

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“In languages all over the world, the word for ‘home’ encompasses not just shelter but warmth, safety, family—the womb.” ~Matthew Desmond

Part of my Summer Social Justice Reading Challenge included reading Matthew Desmond’s powerful nonfiction book Evicted: Poverty and Profit in the American City (New York: Crown Publishers, 2016). Although I finished reading the book a month or so ago, I’ve been letting my thoughts about it percolate before writing a review.

First, it is a formidable book, with the hardcover edition being 341 pages with an additional 62 pages for a detailed “Notes” section. Since the author is a Harvard University professor and Evicted is based on his PhD dissertation research, the scholarly weightiness of the book is not surprising. As Desmond points out, there has been a dearth of research on the practice, policies, and consequences of eviction on individuals, families, and groups in the United States. Through his research and policy work, he seeks to address this issue. He has established the Just Shelter website to highlight additional stories of evictions around the country and to direct people to ways of helping at the local and national levels. For that I admire him.

In an effort to tell the stories of people he studied and lived amongst (in order to study them), Desmond uses a third-person detached narrative approach similar to the one used by Katherine Boo in Behind the Beautiful Forevers: Life, Death, and Hope in a Mumbai Undercity (New York: Random House, 2012). In the “Notes” section he acknowledges that he declined to write in the more current first-person ethnographic narration, a “…postmodern turn in anthropology, which focused attention on the politics and biases of the author.” He goes on to invoke “classic” policy-relevant ethnographic books, such as Elliott Liebow’s Tally’s Corner: A Study of Negro Streetcorner Men (New York: Little, Brown &Company, 1967), in which he claims the authors “are hardly on the page.” (p. 405) This is a strange statement, since Tally’s Corner is written in first-person, despite it also being written from Liebow’s dissertation. 

Evicted reads more like a novel (Sinclair’s The Jungle comes to mind) than a heavy-duty social policy book. But as a reader, I was distracted by the frequent use of derogatory descriptors of people (moon-faced, redneck, etc.) and the fact that I could easily tell the places in the story where the not so behind the scenes author would play the role of the Great White (male) hope and bail people out of difficult spots. In the “Epilogue,” Desmond acknowledges both of these issues, but not in particularly convincing or reassuring ways. For instance, he mentions that people sometimes call him on the fact that he includes not so savory details about “poor people” and he replies that it doesn’t help anyone to try to gloss over realities—and that the tendency of kind-hearted liberals to portray poor people as saints is belittling and disrespectful. I agree, but there’s no need to describe people in a pejorative way.

The strongest part of Evicted comes in the “Epilogue: Home and Hope.” It is here that Desmond does an excellent job of highlighting the negative health effects of eviction on people, including the higher rates of depression and suicide among recently evicted people. And he has these things to say about the role of home for all of us: “The home is the center of life. It is a refuge from the grind of work, the pressure of school, and the menace of the streets.(…) The home is the wellspring of personhood. It is where our identity takes root and blossoms (…) When we try to understand ourselves, we often begin by considering the kind of home in which we were raised. (…) America is supposed to be a place where you can better yourself, your family, and your community. But this is only possible if you have a stable home. ” (pp. 293-4) Yes, housing is health care and yes, everyone deserves a safe and stable home.

The Pebble in My Shoe

IMG_1805“I write about what most fascinates me right now,” said John McPhee, by way of Robert Michael Pyle, both amazing trail-blazers, or perhaps trackers, of that strange beast that is creative nonfiction. McPhee has written books on subjects such as oranges, the island of his Scottish ancestors, family doctors, college basketball players, the shad as Founding Father fish, and the history of the birch-bark canoe (my personal favorite). Pyle, who is also a biologist, a lepidopterist (butterfly expert), and founder of the Xerces Society for invertebrate ecology (saving our butterflies and bees), has written about butterflies and trees and Big Foot and life. My favorite contemporary female trackers of, or perhaps more fittingly, expanders of the boundaries of creative nonfiction are Terry Tempest Williams and Rebecca Solnit. When Women Were Birds: Fifty-Four Variations on Voice (New York: Farrar, Straus, and Giroux, 2012) by Williams and A Book of Migrations (London: Verso, 211) by Solnit remain two of my all-time favorite books.

Each of these great writers of creative nonfiction sweep us along on explorations of their own current fascinations, obsessions, questions–the pebbles in their shoes, as one of my writing mentors, Stephanie Kallos puts it so aptly. What is it that you carry with you, that at each step insistently reminds you of its existence? The pebble of obsession doesn’t have to be a large rock-sized, inscribed with the muse-whisperer one as shown in the photo here (my historian son made that for me a few years ago–coolest present ever!). But is should be of sufficient significance to be likely to matter to other people besides yourself.

My pebble, my obsession, is and has been for many decades now, the wicked problem of homelessness. I call it a wicked problem, not so much because it is evil or immoral (which I happen to think it is), but because it is so vastly complex a problem that it defies easy solution. Hence, all the well-meaning but expensive and time-consuming ’10 Year Plans to End Homelessness’ implemented (much more than 10 years ago now) in so many U.S. cities, and that largely failed. The term ‘wicked problem’ was coined by two UC Berkeley professors of urban planning, Horst W.J. Rittel and Melvin M. Webber, to describe difficult social policy issues such as poverty, crime, and homelessness. (Read their still surprisingly relevant journal article “Dilemmas in a General Theory of Planning” Policy Sciences (4), 1973, pp. 155-169.)

Rittel and Webber write, “As distinguished from problems in the natural sciences, which are definable and separable and may have solutions that are findable, the problems of governmental planning–and especially those of social or policy planning–are ill-defined; and they rely upon elusive political judgment for resolution. (Not ‘solution.’ Social problems are never solved. At best they are only re-solved–over and over again.)” (p. 160)

But who would we be, as individuals, as a society, if we didn’t even try? That is the core question, the obsession, the pebble in my shoe.

Safe Sleep Matters

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

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

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

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

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

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

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Summer Reading Challenge 2016

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

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

Happy and thoughtful and humanistic summer reading everyone!