Tag: Health

When Is It OK to Write About Patients?

DSC01479I write about patients; I ask my students to write about patients. I do this as part of reflective practice and with the knowledge that it can contribute to humanizing health care for patients, families, and health care providers. But writing about patients has to be done in a respectful way, with adherence to certain ethical and legal guidelines. By now we all know that it is not okay to write about patients in an identifiable way, and certainly not on social media platforms while in a knee-jerk, bleary-eyed state. But when is it okay to write about patients and patient care?

Many physician writers I know adhere to fairly strict personal guidelines to only publish stories about patients with the patient’s permission–preferably written permission. Rita Charon, MD of Columbia University’s Program of Narrative Medicine is a staunch advocate of this patient privacy ‘rule,’ as is my colleague at the University of Washington, Sharon Dobie, MD (see her excellent recent blog post “Writing About Patients”).  Nurse writers who I have talked to about this (like Theresa Brown, RN who writes for the NYT Well blog) point out that hospital hierarchies and power differentials make it much more difficult for nurses to be able to seek patient permission to publish a story about them. The nurse writers also make the case that in many clinical situations, tracking down former patients to seek such approval would itself be a breach of patient privacy under the federal HIPAA (Health Insurance Portability and Accountability Act) rules.

When I write personal narratives for publication I alter some biographical details of patients and change their names in order to protect their identities. I typically don’t change the names of co-workers and friends, and when I do I clearly indicate that in the text. My most recent published essay, “No Place Like Home(less)” (Pulse: Voices from the Heart of Medicine, 5-30-14), was really about me as the ‘patient’ and I purposefully left out names of co-workers since it wouldn’t have added anything (except length) to the essay. I avoid the use of composite patients (merging together details of two or more patients into one) because to me that enters the realm of fiction and I mostly stick to writing non-fiction. One recent exception to this though is my non-fiction/fiction piece “Steps to Footcare” (The Intima: A Journal of Narrative Medicine, February 2014). It was published as fiction because that’s the category I submitted it under. If I were to include it in a print book collection in the future (something I plan to do), I will most likely have it as a non-fiction essay with an explanation of how I crafted the essay.

Here are some current journal submission guidelines pertaining to writing about patients:

Pulse: Voices from the Heart of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine:

“Does your piece describe a patient? Pulse–voices from the heart of medicine is committed to protecting a patient’s right to privacy. Ideally, you will obtain written permission from any patient you write about; as an alternative, you must change his or her name and omit or alter other identifying characteristics. A reader should not be able to pinpoint a neighbor, friend or family member as the subject of your writing.”

The Intima: A Journal of Narrative Medicine, Columbia University Program of Narrative Medicine:

“Patient Privacy Notice
The Intima adheres to legal and ethical guidelines in accordance with academic and health community publication standards.  As clinicians, patients, and family members, we feel strongly that patient privacy and confidentiality be maintained at all times.  We simultaneously recognize that narrative power depends on intimate, singular encounters and the sharing of personal accounts in a respectful and safe environment. To maintain these standards, contributors should review the confidentiality guidelines in the Health Information Portability and Accountability Act (HIPAA), with particular attention to the 18 commonly accepted “unique identifiers.” We also encourage contributors to seek permission before submitting patient stories, and to fictionalize or change identifiable information whenever possible and appropriate to maintain patient confidentiality and privacy.”

 

American Journal of Nursing, Reflections (personal narratives):

“CONFIDENTIALITY Please use fictional names for all persons and institutions in your story. Locations may also have to be disguised.”

 

Storytelling for Policy Advocacy

PoppyStoryTimeWhen I tell people that my work focuses on narrative advocacy, they mostly look at me funny and ask, “What’s that?” It is a more concise way of saying ‘storytelling for policy advocacy.’

A common definition of narrative is a story with a teller, a listener, a time course, a plot, and a point. Storytelling is as old as campfires and cave-dwelling. (The photo here is of my father telling Appalachian ‘Tall Tale’ stories to his grandchildren). Storytelling is how we learn about our world, about ethical living, about history, about ourselves. Within the healthcare arena patients and family members tell their stories to nurses and doctors and other members of the healthcare team. It is still a truism that something between 80-90% of the information needed to make a correct medical or nursing diagnosis comes from the patient’s history, from their story.

Storytelling and story-listening are not only important at the individual patient level. They are also important at the community and public health level. Stories can be effective ways to educate and persuade the public and lawmakers on a variety of health and policy topics. Storytelling  (pathos) is part of Aristotle’s three essential components of rhetoric: the art of persuasion. The other two components of rhetoric are logic/reasoning/facts (logos) and the credibility of the speaker (ethos).

Several years ago at The Examined Life: Writing and the Art of Medicine Conference at the University of Iowa, I co-led a workshop “Narrative Advocacy: Writing Lives, Making Changes.” My co-leaders were Marsha Hurst, PhD, a core faculty member in the Program in Narrative Medicine at Columbia University, and Carol Levine the director of the United Hospital Fund’s Families and Health Care Project in NYC. Here’s the abstract of our workshop, which I still refer back to as my own guide and articulation of what I am passionate about:

“Narrative advocacy is the practice of using narrative competencies to advocate for improvements in care. It involves moving beyond the individual stories, to include the connections made within the wider community, and acting upon common interests in order to effect positive change in clinical care, in institutions of caring, and in health policy. In the U.S. there is a long history of health advocacy built on narratives of lived experience of illness and disability, and more recently, grassroots narrative advocacy has expanded through the use of social media. For health care providers and students in the health sciences, narrative advocacy can be a powerful avenue for engagement in health policy because it connects the unique individual experiences with larger issues. As powerful as narrative advocacy can be to engage and persuade policy-makers, it can and has been misused. It is important to have both knowledge and skills in how and when to use narrative advocacy responsibly and ethically.”

This past week I had the opportunity to participate in an excellent online training “The Role of Narrative in Public Health” sponsored by the Center for Digital Storytelling located in Berkley, California and facilitated by Amy Hill. She gave four reasons personal stories are so powerful: 1) stories are universal and typically follow a familiar structure, 2) stories are intimate and touch the heart in a way facts/figures can’t, 3) stories are honest and aren’t as slick and sensationalized as they often are in journalism, and 4) stories don’t (typically) tell us specifically what to do. The Center for Digital Storytelling uses a participatory media and group process to help people create and share their personal stories. Working in groups makes the individual stories more powerful, and the process can be empowering and healing for the participants.

The Center attends to the ethical practice of digital storytelling (would be the same for any type of narrative/storytelling work I think). They ensure storyteller well-being, use principles of cultural humility, and adhere to a set of guidelines in working with people impacted by trauma. They point out that consent is an ongoing process, that the question of story ownership and of sharing and distribution of the stories should be clearly addressed from the very beginning of the project. Amy showed us several powerful digital stories from their various projects. My favorite was on motherhood and women’s rights from their “Silence Speaks” project: Dear Ayhan by Rawan Bondogji. A perfect story for Mother’s Day. It is beautifully done.

Here are some additional narrative advocacy pieces that I use in my teaching:

 

 

 

 

 

 

 

Child Abuse and Sexual Assault Prevention

IMG_1919April is both National Child Abuse Prevention Month and National Sexual Assault Awareness and Prevention Month. Both are complex, dark, depressing subjects that most of us would rather not talk about. Perhaps that is why they both have their official ‘months’ during one of the most beautiful, spring, hope, and renewal times of year. I’m writing this post on the last day of April partly because I’ve procrastinated and wanted to avoid the topics myself. But I am also ambivalent about the practice of observing national months of awareness of such important public health issues, since awareness and prevention efforts should happen every month, every day, by all of us. These are societal issues that we are all implicated in perpetuating if we do nothing to stop them.

I want to acknowledge the hard work of all the wonderful school nurses, sexual assault center nurses, counselors, and other support staff who work with children and adult survivors of child abuse and/or sexual assault. Having worked as a nurse practitioner in several domestic violence shelters, in urban safety net hospital emergency departments, and with street-involved youth (with high rates of both childhood abuse and sexual assault on the streets), I know first-hand how emotionally challenging this work can be. It is important work, so let’s support them in any way we can.

Here are some of my favorite current resources related to child abuse prevention and sexual assault awareness/prevention:

National Child Abuse Prevention Making Meaningful Connections 2014 Prevention Resource Guide, by DHHS, Administration for Children and Families. (Full disclosure: I was a health care provider consultant on the development of this guide but there were hundreds of consultants/contributors including community and family members).

Moriah Silver’s Huffington Post article “The not so shocking news about campus sexual assault,” (4-29-14). (Shame on us at colleges/universities!)

National Sexual Violence Resource Center.

National Sexual Assault Hotline (1-800-656-HOPE) by RAINN (Rape, Abuse, and Incest National Network).

And this quote, from the last poem of a lovely collection of poems sent to me by Jane Seskin, a longtime therapist in NYC who works with women dealing with intimate partner violence:

“The Take-Away

Repeat/ 3 times a day.

I’m grateful/to be alive.

I deserve to be treated/with kindness and respect.”

(From: Witness to Resilience: Stories of Intimate Violence, 2013, Jane Seskin.)

My Young Invincible, His Lost and Found Toe, and University Health Insurance That ‘Technically Isn’t’

IMG_1225 - Version 2Last fall I wrote about my 26-year-old son who lost his right big toe in a freakish university gym accident a day after his student health insurance officially took effect. (See my blog post Young Invincible Health Insurance Saga 10-5-13). He had aged out of my university job-based health insurance three months before and, much to my consternation, had ‘gone bare,’ unable to afford any of the health insurance plans available to him at that time. He signed up for the University of Washington’s School Health Insurance Plan (SHIP) as soon as he started in a graduate program there. As I drove him to the (University-affiliated) emergency department with his (found) toe, and then as a wonderful physician cheerfully sewed it back on, I breathed a huge sigh of relief that his SHIP would at least cover most of the cost.

Although, on second thought, as I wrote then:

“Even though he officially has health insurance to cover his expensive ED visit (X-rays, sutures, IV Vancomycin, physician quips) and ortho follow-up, I do not trust it. There are pages upon pages of exclusions to his health insurance plan, including bungee-jumping and intercollegiate sports–neither of which would seem to apply to losing a toe in ballet/karate. But I know how crafty and devious health insurance companies can be in trying to deny medical claims. I would hope that the university where I am employed and teach (and where my son is now a student) would have a decent health insurance plan option for its students. I guess I’m about to find out.”

And now, almost seven months later, I have discovered a very surprising answer: his university health insurance ‘technically isn’t health insurance.’ Silly us for assuming that something called a ‘Student Health Insurance Plan’ offered through a major U.S. public university was really health insurance!

This was explained to me today by a nice young representative who answered the phone at LifeWise, the insurance company that underwrites and administers University of Washington’s SHIP. I called to ask (nicely) how it was that they could still legally include a pre-existing condition exclusion since ACA/Obamacare requires insurance companies to cover people with pre-existing conditions (including the ‘pre-exisiting condition’ of being a woman, for which insurance companies charged more). I had done my homework on this, reading the user-friendly Healthcare.gov website to find that there was one exception to this rule: the benignly named ‘grandfathered individual health insurance plans.’ I wanted to know how SHIP could possibly qualify for this ‘grandfatherly’ exception category, and if they did, why they didn’t include that statement clearly in their information brochure as mandated by the ACA. LifeWise has hassled my son to prove that his torn off toe wasn’t a pre-existing condition and has refused to pay for some of his other healthcare claims.

The LifeWise representative’s answer was that they weren’t a grandfathered plan, but that they didn’t have to follow many of the ACA mandates because ‘technically this isn’t a health insurance plan, it is a disability plan.’ Huh? She went on to explain that the fine-print ‘Note’ clause on the front page of their consumer brochure ‘clearly states this.’ I had the brochure on the screen in front of me and sure enough, right under the large purple banner/title “University of Washington/ Seattle ‘SHIP’ Student Health Insurance Plan” it has a teeny tiny “Note:This coverage is blanket disability insurance. Coverage provided is “excess” only and does not contain a “coordination of benefits” provision.” 

That is so (not) clear and transparent for any self-respecting university-attending Young Invinsible, not to mention their University Professor parent who, oh I don’t know, perhaps has a doctorate in health policy? Now I happen to have both ‘real’ health insurance and ‘real’ disability insurance through my university job and I know the difference between them.When I asked the LifeWise representative to please explain how SHIP was really S-DIP I suppose, she replied that she really couldn’t explain it: “of the hundreds of different insurance plans I deal with, this is a unique policy.”

Unique indeed. How can a university (‘my’ university no less) offer what it clearly labels ‘student health insurance’ when it isn’t really health insurance and therefore doesn’t have to comply with current ACA mandates? What will it take for our country to get a saner health care system?

 

Selfie-Healthy Health Care

IMG_1897 - Version 2What does Obamacare/ACA mean to me in terms of my personal health care now that the 2014 roll-out is officially in place?

I have the same job-based health insurance through the same health insurance company that I’ve had for the past two decades. I’m sure that they have continued to raise my deductibles and co-pays this year as they have in most years, but, truthfully, I have ceased to pay much attention to those details.

The biggest change that certainly has gotten my attention was a recent mailing I received with the following highlighted in bright orange: “Premium surcharges and a wellness incentive are coming! Take action on the four steps below.” I knew these were coming and had already taken their wellness survey back in December just for grins (see blog post My New Year’s Resolution: Avoid Wellness Programs, 12-30-13). As the blog post title implies, I had planned to ignore this Big Brother naughty or nice-style intrusion on my sense of privacy, but then I read the next highlighted item on the mailing: “What happens if I don’t respond…?” Answer: I’d start being charged a $25 per month tobacco use surcharge (even though I am a never smoker) and I’d forfeit a $125 reduction on my 2015 medical deductible. Opting out this year would cost me $425. The ACA/Obamacare allows employers to offer larger health/wellness incentives, up to 30% of the cost of coverage, so my health insurance company could hike up these ‘incentives’ (penalties?) considerably in the future.

Begrudgingly, I signed onto their website to attest to not using tobacco products. Then I chose a primary care provider (who I haven’t seen in two years because she is too popular/busy/on her way to becoming another burnout statistic). Then I had to re-take their silly, non-evidence based health assessment. It still tells me I need to stop eating a high-fat diet when I’m a vegetarian. Finally, I registered for one of their wellness program activities: doing at least 90 minutes of moderate to vigorous physical activity per week for at least 10 consecutive weeks. Walking, swimming, cycling, yelling profanities at my health insurance company and our health care system…..Great. OK. Go away you silly premium surcharge/personal wellness incentive that raised my blood pressure!

Just when I thought I was done with all of that for the year, I got an e-mail invitation from my insurance company inviting me to enter a HealthieSelfie photo contest on their Facebook page. All I have to do is ‘snap a selfie’ of my wellness goals and send it to them, to what? share with all their other selfie health care absorbed health plan enrollees? The ultimate of (flat, fit, no flab allowed) navel-gazing healthism? An example of medical sociologist Deborah Lupton’s imperative of health? A fun, harmless, effective way to use social media to promote personal health (and thereby enable the health insurance company to reap more health plan profits)? Yes to all of the above.

Having never taken a selfie before, my first attempt resulted in a photo of my thumb. I find deep symbolism in that. The photo here is my second attempt, and shows me ‘doing’ my 2014 selfie-wellness goal: Less time trying to figure out our crazy health care system and more time in my garden playing with my Corgi.

The Intima: A Journal of Narrative Medicine

IMG_0678In case you haven’t run across this journal before, I encourage you to check out The Intima: A Journal of Narrative Medicine. It was created by some of the students in  the Narrative Medicine Master’s Program at Columbia University. They state, “…we seek an ongoing mode of self-expression as a group, to continue outside the classroom that which was created within. With that in mind we call ourselves and our efforts The Intima, resonating on the concept that Narrative Medicine defines itself as the intimate interface between two people, one as healer, one as being healed, yet both yielding and both gaining from the experience. (…) The Intima is an electronic journal dedicated to promoting the theory and practice of Narrative Medicine, an interdisciplinary field aiming to enhance health care through the development of effective communication and understanding between caregivers and their patients. By providing an online venue for the expression of personal experience within the medical arena, The Intima creates space for caregivers, professionals, patients, and families to share their narratives in a format that fosters empathy, reflection, and deeper understanding of the diversity inherent in effective delivery of care.”
In their Spring 2014 edition under Fiction, I have an essay “Steps to Footcare” about my work as a faculty preceptor with the University of Washington’s Teeth and Toes Clinics, where we provide basic foot and dental care to Seattle’s homeless population. This particular essay takes as its form the actual list of instructions we give students to follow when providing care. I fictionalized it by creating a composite female character based on several ‘real’ patients.

New Zealand Postcards: Cultural Safety: A Wee Way To Go

DSC01879 - Version 2DSC01418This week I had the good fortune of meeting with Denise Wilson, RN, PhD, a Maori New Zealand nurse and Director of the Taupua Waiora Centre for Māori Health Research at AUT School of Public Health and Psychosocial Studies here in Auckland. She talked about her work with cultural safety in New Zealand.

Like many indigenous peoples across the world–including our own in North America–Maori cultural conceptions of health and well-being tend to be much more holistic and less individualistic than mainstream Western ones. As Ms. Wilson explained, for most Maori patients she has worked with (clinically and in research), spirituality and connection with their land and extended family are the most important aspects of health. The Maori word for land, Whenua, also means placenta: it is what nourishes you. The history of colonialization, and being displaced from ancestral lands, have had profound negative effects on Maori health and well-being.

The term ‘cultural safety’ came from a Maori nursing student, Iriphapeti Ramsden (1946-2003), who in the early 1980’s stood up in class one day and asked something like, “We talk about patient safety, physical safety, and ethical safety, but what about cultural safety?” She was specifically referring to the difficulties Maori patients and their families (as well as Maori nursing students such as herslef) have within the Eurocentric health care system in New Zealand. These difficulties continue to contribute to New Zealand’s large health inequities and low representation of Maori nurses and other health care providers in the healthcare system. Ramsden went on to receive her PhD, developing the concept and practice of cultural safety. I discovered that Dr. Ramsden was part of the New Zealand feminist Spiral Collective, which ‘self-published’ Maori writer Keri Hulme’s book The Bone People after it was rejected by all major publishers. The Bone People, of course, went on to win the Man Booker Prize. One of my all-time favorite books, I assigned it as our New Zealand study abroad Common Book this quarter.

According to Denise, a culturally unsafe practice is “anything that diminishes, demeans, or disempowers the cultural identity and well-being of an individual.” A culturally safe or unsafe practice is determined by the patient and the patient’s family (another form of what we term in the U.S. ‘patient-centered care.’) Denise told me that a good ‘cultural safety’ question nurses can ask patients (and their family members) is, “What are things that are really important to you that we need to consider in your care?” Cultural safety includes an emphasis on self-reflection (and action) by the nurse in terms of understanding his or her own cultural and social attitudes that affect their care of patients and communities.

Cultural safety has been taught in New Zealand nursing programs for over twenty years. Since 1992 it has been a requirement for nursing and midwifery registration examinations. What started off as a bicultural focus (Maroi and Pakeha/non-Maori), has been expanded to include things like migrant status, gender/sexual orientation, socio-economic ‘class’ status, and disability. The concept of cultural safety has been adopted by regions in Australia, Canada, and the United States. Denise acknowledged the significant advances that have been made in New Zealand in terms of cultural safety, but she concluded with: “We do have a wee way to go.”

Cultural safety seems to have much in common with my favorite U.S. ‘cultural’ concept of cultural humility, which I have written about in a previous post. Cultural humility was developed as a concept by the African-American physician-nurse duo Tervalon and Murray-Garcia in their 1998 article, “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education.” (Journal of the Poor and Underserved, 9(2) 117-125.) Since then, both the practice and concept of cultural humility have been further refined. Cultural humility emphasizes: 1) a commitment to lifelong learning and critical self-reflection, 2) recognizing and changing power imbalances, and 3) developing institutional accountability. Take a look at the excellent 30-minute video Cultural Humility: People, Principles and Practices by San Fransisco State professor Vivian Chavez.

Even closer to (my) home of Seattle, the historical roots and “remnants of our unresolved past” of racism and classism are powerfully presented in Shaun Scott’s short documentary A Really Nice Place to Live. In the film, Shaun Scott points out that Seattle is a byproduct of White Western Frontierism. He references historian Richard Drinnon’s work on the ‘Metaphysics of Indian-Hating,” where Drinnon asserts that all of American’s domestic and international race and class dynamics can be traced back to our original interactions with our ‘own’ Indigenous peoples.

We all have a wee way to go in terms of addressing and redressing the effects of racism and classism and all the other ‘isms’ of the world.

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The first photograph here is of the friendly and informative staff at the Alliance Health booth at Auckland’s annual Pasifika Festival, which I attended this past weekend. The staff members were promoting community awareness and prevention of rheumatic heart disease. New Zealand has the highest prevalence of rheumatic heart disease of all industrialized countries, and the highest rates are among Maori. It is a result of untreated ‘strep throat’ and is considered a disease of poverty. One of their community-led ‘interventions’ was the creation of Mama’s House as a culturally-appropriate way to engage the Pasifika community.  “Knowing that mothers, sisters and aunties are the first port of call about all matters relating to family health and well-being. After all, ‘Mama knows best’.” It also happened to be International Women’s Day. (And I also had just played ‘Mama-Nurse’ for some of my students who had developed penicillin- resistant strep throat, resulting in some ‘interesting’ interactions with the New Zealand healthcare system, which–like our own–has ‘a wee way to go.’)

The second photo is an interactive game show called “The Survivors,” part of the Maroi section of Wellington’s excellent Te Papa Museum exhibition Slice of Heaven: New Zealand’s Twentieth Century History. As this photo shows, one of the decisions you have to make while playing the game is whether you (as a Maori young woman in the 1970’s) went to the shorter/cheaper nurse aid program or to the longer/more expensive (and heavily Pakeha/’White European’) program to become a Registered Nurse. Guess which choice led to better outcomes, including lifespan for this woman?

Green Beyond Death

indexThis is a shout-out to the work of a former nursing student of mine, Hunter Marshall. He is now a hospice nurse, as well as an environmental and death with dignity advocate, community activist–and a  talented writer! Check out his recent article “Dying to give back to the earth” in Waging Nonviolence (3-3-14).

Hunter told me that he is actively pursuing writing as a mechanism for continuing his patient/policy advocacy: “I particularly enjoy using narratives about individuals that intersect with larger policy issues.” Another rebellious nurse (and writer) in the younger generation warms the cockles of my older nurse/writer heart!

New Zealand Postcards: Misogyny In Sheep’s Clothing (with a G-String)

DSC01009I preface this by saying: I know the Biblical quote that it’s easier to see the speck in another person’s eye than to see the plank in your own. In the U.S. we have a lot of work to do in terms of overcoming misogyny in all its ugly forms (including commercial sex trade/exploitation or perhaps even all the books by Philip Roth?) We have a very large plank, especially in places like Nevada.

But I have to say that one of the most surprising things I’ve learned while in New Zealand these past months is the country’s level of violence against women. Before coming here I mainly knew that New Zealand was rightly proud of the fact that it was the first country in the world to give women the right to vote (in 1893). I also knew that there was a healthy cadre of New Zealand feminists at work influencing national policy through research, direct service, and the arts. What I had not realized was how deeply ingrained the sexism is here, perhaps as yet another direct descendant of British colonialism? That is what one of my Maori female informants and experts on this topic asked somewhat rhetorically in answer to my question to her about this topic. I had not realized that prostitution is legal in New Zealand (the photo here is of the Calendar Girls strip club/’gentleman’s club/brothel left standing in the Red Zone of Christchurch.) I had not realized that New Zealand is one of the worst industrialized countries in terms of violence against women. (See: Facts on Violence Against Women, by Janet Fanslow, New Zealand Herald, 11-25-11.)  Of course, those issues are all interrelated.

A society’s level of sexism and misogyny, plus tolerance of violence, plus racism, plus poverty, plus sexualization of girls, plus a high level of commoditization and commercialism, are all documented risk factors for commercial sexual exploitation (CSE) of girls and women. Additional environmental risk factors for CSE include: open presence of the adult sex industry, transient male populations, and proximity to borders/ports.

I have spent many decades as a nurse working with homeless and prostituted teens and young adults on both coasts of the U.S., as well as in Thailand. There was a time during the early part of the HIV/AIDS epidemic when I bought the idea of sex trade as potentially being empowering work for women, along the idea that legalizing and regulating (including health screens) prostitution/sex work were all good things. But that belief was short-lived when I realized how dangerous the work is, no matter how ‘upscale’ or regulated or sanitized. And when I realized (from both credible research reports and stories from young women I worked with) that the women and children in prostitution anywhere in the world come from the most marginalized and oppressed groups in society. And how many (upwards of 90% in many studies) have untreated PTSD and histories of sexual abuse as children. And there is mounting evidence that legalizing prostitution only increases human/sex trafficking.

Efforts like those in my home state of Washington to decriminalize prostitution for the women/men/girls/trans in sex work (and refer them to appropriate services), while simultaneously stepping up the severity of prosecution of the buyers (‘Johns’) and the traders (‘Pimps’), make the most sense to me. Meanwhile, Nevada has counties near places like Las Vegas where prostitution is not only legal. They lock women inside barbed-wire secured brothels called ‘ranches,’ and then busloads of ‘customers’ arrive to be serviced. Like I said, we have planks in our own eyes.

Nurses and other front-line primary care providers need education and training in how to identify and effectively work with children and adults involved in CSE. Similar to gaining skills in working with victims of intimate partner violence, any screening or intervention is based on building rapport, maintaining appropriate professional boundaries (including not ‘rushing in to the rescue’), understanding PTSD and trauma bonding, using the principles of harm reduction to help the client build a safety plan, and knowing good community resources for appropriate referrals. One important health component I’ve found to be essential is having culturally-clued in positive body work (like yoga) to refer people to. It helps them get cued in to what the body can do, instead of what is done to the body (body as object). And for anyone who doesn’t know how to ask a patient about this topic, here’s the standard screening question: “Have you ever traded sex for money or other things needed to survive?”

And remember the words of Gloria Steinem: “Prostitution isn’t the world’s oldest profession. It’s the oldest oppression.”

Resources:

Polaris Project: For a World Without Slavery

The Washington Anti-Trafficking Response Network: 206-245-0782

National Center for Missing and Exploited Children: 1-800-THE-LOST

National Human Trafficking Resource Center Hotline: 1-888-373-7888

An excellent 5-minute training/education video about the process of ‘grooming’ that can draw young women into prostitution: GEMS The Making of Girl.

New Zealand Postcards/ Disaster Preparedness: Lions and Tigers and Zombies and Earthquakes, Oh My!

DSC01509There are many things to worry about in this world. For instance, right now in my hometown of Seattle, the Alaskan Way Viaduct is sagging a bit due to the large-scale drilling going on in the downtown area. The Alaskan Way Viaduct is built on ‘reclaimed land’ from Puget Sound that would most likely turn to liquefaction in our next earthquake (similar to what happened in the Christchurch earthquakes). But OK—state officials say it’s nothing to worry about.

As I write this post I am sitting on a ‘somewhat active’ series of volcanoes, on land that was covered in a hot mud eruption only ten years ago. Rotorua, on the North Island of New Zealand is a hot mess. The youth hostel we are staying in has fire action directions in each bedroom, but no information about what to do in case of an earthquake–or a volcanic eruption.

Disaster preparedness and effective disaster messaging are important components of public health. In the U.S., disaster preparedness communications specialists came up with the  Zombie Disaster Preparedness Campaign. Supposedly this campaign started out as a joke by a CDC communications specialist frustrated over the lack of public interest in their traditional disaster preparation information. But then the Zombie Campaign became so effective they’ve continued to use and expand upon it. This shows that with the ‘Chicken Little’ dire warnings of impending doom, a little levity can help.

Last week in Wellington, we talked with Sara McBride, a PhD candidate at Massey University at the Joint Center for Disaster Research. (The photo here is of the inside of their Emergency Operations Center where they coordinate disaster response for the university and conduct trainings). Her area of expertise is as a risk communicator, work which she was doing in Christchurch before the earthquakes. She told us that disaster communication is tricky because too much emphasis on doom and gloom results in people becoming fatalistic. Ms. McBride is currently doing research and work on earthquake/disaster preparedness and messaging in Washington State (where she grew up). As Professor Timothy Melbourne writes in his guest editorial in today’s Seattle Times, the Seattle area is at high risk for major earthquakes and tsunamis on the scale of those in Japan three years ago (“What Our Region Has Not Learned from the Japan Earthquake and Tsunami, 2-25-14). He points out that Washington State needs an honest and transparent assessment of building safety (and other structures such as our dams and bridges). This is an excellent ‘health in all policies’ topic for nurses to get involved with.