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!

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.

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.

Red Blanket Patients

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Very Important Patient red blanket. Photo credit: Josephine Ensign/2016

Although one of our country’s founding principles centers on equality, we know that has always been a lofty goal, and one that conflicts with our real guiding principle of rugged individualism combined with economic competition.

Money talks. Money yells. Money gets you red blanket treatment in many of our country’s hospitals. I’m sure the ‘real’ red patient blankets are much prettier than the swatch of one I knitted and embroidered for this photo, but they do exist both literally and metaphorically–and historically. Red blanket treatment’ of patients has historical roots in pre-WWII emergency medicine practice: a red blanket was placed over a patient triaged as needing rapid transfer to a place of higher-level treatment and attention. Presumably, this older type of ‘red blanket treatment’ was done based primarily on medical need and not on patient socio-economic status.

A different version of ‘red blanket’ VIP (Very Important Patient) hospital practices seems to be proliferating. ‘In the NYT Op-ed article “How Hospitals Coddle the Rich” (October 26, 2015), by Shoa Clarke, a physician currently doing his residency at Brigham and Women’s and Boston Children’s hospitals, writes of his experience during medical school (at an unnamed but readily identifiable hospital in California–as in Stanford) of being introduced to the concept of tiered care in hospitals where hospital administrators draped wealthy patients in scarlet blankets to help ensure they got better care. “This is a red blanket patient,” one of his supervising physicians reportedly said. Such red blanket patients are fast-tracked and given preferential treatment based solely on their wealth and status.

In a follow-up post related to this topic on KevinMD, a dermatology resident physician and medical school classmate of Clarke’s, Joyce Park, contends that she has never seen red blanket VIP patients getting better hospital care than other patients. In her very telling statement, “I have not seen this happen, from the level of nursing all the way up to the attending physicians” she manages to sum up the worst of hospital hierarchy-think and to come across as impossibly naive. (“The Problem with VIPs in the Hospital”, November 15, 2015.) Of course VIP patients get better hospital care, at least in terms of an increase in prompt nursing attention (and probably much lower RN to patient staff ratios), as well as more ‘discretionary’ medical and surgical interventions.

What’s ironic with this equation is that while the improved nursing care translates to improved patient outcomes, an increase in medical surgical interventions typically translates to worse patient outcomes. When nurses go on strike, hospital patient mortality increases; when doctors and surgeons go on strike, hospital patient mortality decreases or stays the same. (See the recent multi-country research study results reported in the British Medical Journal, “What are the consequences when doctors strike?” by Metcalfe, Chowdhury, and Salim. November 25, 2015/ and “Evidence on the effects of nurses’ strikes” by Sarah Wright in The National Bureau of Economic Research.)

The reason for this difference most likely lies in the fact that more medical and surgical care does not mean better health care or better objective health outcomes. As reported in a 2012 Archives of Internal Medicine article, “The Cost of Satisfaction,” (by Fenton, Jerant, Bertakis, and Frank) a study using a nationally representative sample found that higher patient satisfaction (with physicians) was associated with increased inpatient utilization and with increased health care expenditures overall and for prescription drugs. Patients with the highest degree of satisfaction had significantly greater mortality risk. The researchers postulate that patients with more clout who can cajole their physicians into giving them more medications and more discretionary medical-surgical interventions may be more satisfied with their care by physicians, but are also more likely to die from iatrogenic causes.

Perhaps–even if you can afford VIP/concierge/red blanket patient care–you should think twice about what you are really buying. And perhaps as a country we should think about where we’re headed with such an increasingly stratified healthcare system.