Gratitude for Mentors

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Dr. Lorna Mill Barrell (1931-2014), a nursing mentor of mine, after lunch in the Jefferson Hotel, Richmond, Virginia in 1996.

We now have the ‘science of gratitude’ to back what we’ve already known: gratitude is good for us, both individually and collectively. That we have a national holiday named for gratitude is something that–despite the complicated colonization and empire-building historical roots–I am thankful for.

Over the past four months, I have had the privilege of interviewing a variety of people in the Seattle area who work (or live) at the intersection of health and homelessness. These interviews are part of the oral history component of my ongoing Skid Road project, exploring the historical roots of ‘charity’ health care in King County, Washington (the county within which Seattle is located). One of the first open-ended interview questions I pose to people is, “Who or what has most influenced your work and life?”

People I interview typically pause for a moment after I ask this question, they gaze at some corner of the room as if seeing pleasant ghosts, and then they launch into detailed descriptions of people and events essential to who they are as people and to the work they do. Most people identify one or two key people in their lives who provided a sort of moral compass steering them in the direction of compassion–for their own humanity, as well as for other people. Parents. Teachers. Counselors or therapists. Professional mentors. They can easily tell a specific story of lessons they learned from these key people. And due to my use of snowball sampling–asking them to identify people I should try to interview–I have been able to complete oral history interviews on several generations of mentors.

These interviews have led me to reflect more deeply on the people in my life I am grateful for, people who have influenced who I am and what I do. I am also reminded of the wisdom of Rachel Naomi Remen, MD and her healing work with physicians, nurses, and other caregivers. I often introduce my students to her Heart Journal daily practice. For this, she advocates a 10-15 minute quiet time at the end of the day where you review your day, then write the first things that occur to you when you ask yourself three questions: 1) What surprised me today? 2) What moved me or touched my heart today?, and 3) What inspired me today?  Attention and gratitude.

As a nurse and a teacher, I remember two people who have had the most influence on my work, my life. One is Lorna Mill Barrell, RN, PhD who came into my life when I was seriously considering dropping out of nursing school. It was in November of 1983, my final year of the BSN program at MCV/VCU, and I had just been informed by my community health clinical instructor that she was giving me an ‘F’ on my final clinical rotation project paper. “I don’t see how this has anything to do with nursing,” she wrote across my project paper’s title, “The Health of Richmond’s Homeless Population.” I contested her grade and that’s how I met Lorna, who was the chair of the department my instructor worked in–she was my instructor’s boss.

I remember Lorna’s welcoming and nonjudgmental attitude towards me when I came into her office to meet with her about my grade. I’m sure I came across at first as indignant, haughty, and angry. At the time, I wasn’t just contesting my community health grade, I was also contesting my desire to be a nurse at all. She offered to read and re-grade my paper. Thanks to her intervention, I not only passed community health (she changed my paper grade to an ‘A’), but she helped convince me to finish nursing school and go straight into their master’s program for becoming a nurse practitioner. She was my thesis advisor and the co-author of my first published academic journal article. Within a year of graduating and starting my first job as a nurse practitioner working with homeless and marginalized patients at Cross-Over Clinic, Lorna hired me to teach a community health clinical course.

The other mentor I draw on as inspiration for my current work is another MCV/VCU teacher–from the medical school though–who I only remember as Chaplain Bob. During my first semester of the BSN program, fresh out of a brief stint in a MDiv medical humanities program, I convinced him to let me take his medical school elective course on death and dying. He approached this topic in our small seminar-style class, from a health humanities perspective, having us read and discuss Tolstoy’s The Death of Ivan Ilyich, among other works of art and literature. He also encouraged us to write our own poetry and short stories. I took that assignment seriously and wrote a chapbook-length collection of poetry. Chaplain Bob gave me an ‘Aa’ (not entirely sure what that grade really is) for the course, but he also enthusiastically encouraged me to continue my creative, reflective writing. I kept that chapbook. And here, impossibly at age twenty-two (meaning–not that it is great poetry but that is impossibly so long ago) , I wrote:

The Process

Sitting by the hour/ listening to the drone: “The Patient. The Client./And don’t forget the Significant Others./ By all means, keep in mind the Nursing Process.”

“We’re training you to be/ Professionals./ We want you to think/ Independently./ Here, take this test/But don’t think too much/just fill in the dots/the computer will understand.”

We learn to forget,/ to not feel, to not know./ It will hurt too much,/ and it certainly won’t help /us to be professionals.

and…

Waiting 

Sitting on park benches/writing their hands/trying to forget the ill one inside/that hospital there/ the building you just stepped out of/ the one you walk by every day/ that structure that has become/ a part of the skyline/ seen from the window of a dorm room.

It is a lab/a place to practice/the proper way/to give drugs/ to make beds/to become a nurse.

But reflected in the eyes/of the park-bench individuals/ the building becomes/ one room/one bed/one person/one fear/one hope.

____   To all my mentors, named and unnamed (and in Bob’s case, half-named): thank you. Remember to pass it on.

 

 

 

Carrying Stories: Beyond Self Care

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Girl with Balloon, street art by Banksy. This one found at intersection of K-Road and Queen Street in Auckland, New Zealand. Photo credit: Josephine Ensign/2015.

What to do with difficult stories? Stories of refugees, victims of mass shootings, of hate crimes, of rape, of torture victims, of people dying alone and unnoticed ?  It all gets overwhelming and depressing to hear or read these sorts of difficult stories, to carry them in our hearts, to bear witness to so much suffering in the world.

Of course, for many fortunate (perhaps unfortunate?) people, there is the option of tuning out these stories, turning off the news, unplugging from any non-vacuous form of social media. Taking a break from difficult stories.

But what about all the other people who cannot or choose not to disconnect? What about people whose work involves listening to these stories on a daily basis? Frontline health care providers who work with people experiencing trauma (physical, emotional, sexual). First responders. Counselors, mental health therapists, lawyers. Human rights activists. Researchers working on social justice issues. What can they do to, if not prevent, at least deal effectively with, vicarious or secondary trauma? And for those of us who teach/train/mentor students in these roles, how do we prepare students to be able to carry difficult stories while maintaining well-being?

In a previous blog post, “Burnout and Crazy Cat Ladies,” I explored the issue of ‘too much empathy’ and of pathological altruism, linking to some of the (then/2011) current research. After writing that post and some related essays, I began incorporating a new set of in-class reflective writing prompts for soon-to-be nurses in my community/public health course. I used these in a class session I titled “Public Health Ethics, Boundaries, and Burnout.”

The first writing prompt: ‘What draws you to work in health care? What motivates or compels you to do this work?’ And then later in the class session– after discussing professional boundaries (how fuzzy they can be), individual and systems-level risk factors for burnout, and asking them to reflect on how they know when they are getting too close to a patient, a community, or an issue–I gave them the follow-up writing prompt: ‘Referring back to what you wrote about what draws you to work in health care, what do you think are the biggest potential sources of burnout for you? And what might you be able to do about them?’

Feedback from students about this in-class reflective writing exercise and the accompanying class content on boundaries and burnout, was invariably positive. Many of them said it was the first time in their almost two years of nursing education that anyone had addressed these issues. I understand that patient care, electrolyte balances, wound care and all the rest of basic nursing education takes priority, but it makes me sad that we don’t include this, to me what is fundamental and essential, content.

“…people who really don’t care are rarely vulnerable to burnout. Psychopaths don’t burn out. There are no burned-out tyrants or dictators. Only people who do care can get to this level of numbness,” Rachel Naomi Remen, MD reminds us in her book, Kitchen Table Wisdom: Stories That Heal (Riverhead Books, 1996). Something to remember when we are feeling overwhelmed by difficult stories.

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Here are some excellent resources:

 

Dorothy Day and Nursing

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From Creative Commons

Dorothy Day is known for her work in social justice, and especially for her co-founding and longtime work with the Catholic Worker Movement. Earlier in my career I worked with the Richmond, Virginia-based Freedom House, modeled after Day’s houses of hospitality. Freedom House, like Day’s original house of hospitality in the Lower East Side of NYC, included a shelter, soup kitchen, laundry and clothing services, counseling and friendship. The staff members of Freedom House lived in voluntary poverty as a mark of solidarity, and as a way to become un-insulated from the realities of poverty and homelessness.

I also knew that Dorothy Day had been a journalist and had been involved with the women’s suffrage movement. She picketed the White House in 1917 as part of the Silent Sentinels’ nonviolent civil disobedience, and was arrested and jailed for her part in the peaceful protest.

But, I had no idea that Dorothy Day was also a nurse. I discovered that fact recently when I read her autobiography, The Long Loneliness (Harper and Row, 1952). In 1918, as WWI and the influenza pandemic raged on, Dorothy wrote to a friend: ‘I hate being Utopian and trying to escape from reality . (,,,) What good am I doing my fellow men? They are sick and there are not enough nurses to care for them. It’s the poor that are suffering. I’ve got to do something.”

So she went to work as a nurse–or a nurse-in-training– at the Kings County Hospital in Brooklyn. She writes of this time: “From the beginning I enjoyed the work. (…) My experience there reassured me as to the care one received from the city. It was a care given to citizens, not to paupers. And it was all free.”

In her autobiography, she describes specific patients and hospital wards that were particuarly memorable to her. Two female patients dying near each other in a ward, one a woman of fifty and the other a girl of twenty-two. Of the younger patient she writes, “There was the smell of death around her, I kept thinking, and there was no one to bring her flowers to deaden it.” She moved to a fracture ward. ‘This ward broke me, the work was so hard. (…) One afternoon when I had been cleaning up filth all day, and the perverse patient had again thrown her bedpan out on the floor dirtying my shoes and stockings, I left the ward in tears and sat in the washroom weeping uncontrollably at the ugliness and misery of life.” Day claims that she had a sympathetic nursing supervisor who took her off the difficult ward, “… transferring me to medical where there were fifty patients with influenza.” (I’m not so sure I’d call her supervisor sympathetic.)

We forget how devastating the 1918 flu pandemic was: “This was the time of the ‘flu’ epidemic and the wards were filled and the halls too. Many of the nurses became ill and we were very short-handed. Every night before going off duty there were bodies to be wrapped in sheets and wheeled away to the morgue. When we came on duty in the morning, the night nurse was performing the same grim task.(…) It was hard not to be careless at this time when every day ten or twelve new patients were carried in or walked staggeringly only to fall unconscious as soon as their clothes were taken from them.”

Of burnout and emotional numbing in her work a a nurse, Day writes this: “Nursing was like newspaper work. It was impossible to suffer long over the tragedies which took place every day. One was too close to them to have perspective. They happened too continuously. They weighed on you, gave you a still and subdued feeling, but the very fact that you were continually busy left you no time to brood.” She writes of finding solace and peace outside in the hospital grounds: “I just sat for a brief rest and watched the sparrows and starlings looking for crumbs from the apron pockets of the old women. ”

Dorothy Day worked as a nurse at the hospital for a year, until after the influenza epidemic was over. “Then a longing to write, to be pursuing the career of a journalist which I had chosen for myself, swept over me so that even though I loved the work in the hospital, I felt it was a second choice, and not my vocation. My work was to write and there was no time for that where I was.” She concludes this chapter of her life by writing, “…I had been a good and sympathetic nurse. I knew that I loved the work, and that if I had not had the irresistible urge to write, I would have clung to the profession of nursing as the most noble work (…).”

Nurse Dorothy Day, along with suffragist/activist/radical hospitality Dorothy Day: an inspiration.

Health Care Bucket Lists

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Bucket list: a list of things you want to accomplish before you die. Derived from the saying, “kick the bucket,” a euphemism for dying–although no one seems to agree on the derivation of “kick the bucket.”

I recently ran across my own bucket list that I wrote when I was twelve years old. I wrote it as part of a seventh grade creative writing assignment. My mother kept all of my childhood writing and presented the packet to me before she died–something for which I am eternally grateful. My short stories about toothbrushes coming to life give me glimpses of my younger self that cannot be accessed through any other medium. Here is my bucket list at age twelve:

  1. Own a pair of sandhill cranes
  2. Have a zoo where all the animals can run free
  3. Have a greenhouse as big as a football field
  4. Learn to ride a unicycle
  5. Go to Australia
  6. Keep an otter
  7. Build my own house over-looking a lake
  8. Write a children’s book

I believe that I wanted to be a writer, a naturalist, or a veterinarian–most definitely not a nurse. My favorite books were (not surprisingly by my bucket list), Aldo Leopold’s A Sand County Almanac and Gavin Maxwell’s Ring of Bright Water.

What would my bucket list, my hopes for the future of health care be like? Since I am no longer young and idealistic, my health care bucket list comes out sounding way too jaded and cynical. So I turned to question to my younger and hopefully still idealistic senior nursing students. “What are your hopes for health care?” was my specific in-class reflective writing question to them a week or so ago. I asked them to write out a list of their top ten hopes.

Out of the 140 or so students, the vast majority listed some version of “universal access to quality and affordable health care.” Another frequently listed item was “provision of culturally humble health care,” as well as “eliminate racism in healthcare.” Many included ‘an emphasis on community-based primary health care,” and “more funding for public health.” Improved patient safety efforts, especially through good interprofessional health care team communication and safe nurse-to-patient ratios in hospitals, was a top-listed item. Closely related to that was “improve working conditions to reduce nurse burnout.” Improved access to better mental health services (including the astutely stated question “why are mental health units so ugly?”) and reducing stigma for mental illness and substance use issues, were also frequently mentioned. “Improving end-of-life and beginning-of-life care” as a way to improve quality of life as well as better use of our health care dollars was another top choice.

Here are some additional student ‘hopes for health care’ that make my heart sing and that give me more than a bucketful of hope for the future of health care:

  • To see the person, not the illness.
  • To create a nursing image that represents our smarts and not just our compassion (and nurses aren’t asked, “why didn’t you become a doctor?”)
  • To have more nursing involvement in policy change. Use my knowledge of the challenges faced by my patients to inform policy advocacy.
  • To ensure that ‘the least among us’ receives the best care possible, and “that I am courageous and prepared enough to advocate for the least among us.”
  • That we realize our patients have backstories that need to be recognized in order to provide the best care for them.
  • Full scope-of-practice for nurses uniformly across the country.
  • I hope I still have hopes for the health care system.

I am a Nurse, Just a Nurse

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

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

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

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

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

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

What is Public Scholarship?

IMG_3174My irreverent answer: work done by nerdy, bookish, abstruse (yes, abstruse), people with way too much formal education who can get over themselves enough to care about the ‘real’ world, what’s going on in it, what they might have to offer it on a more practical level, and what they can learn from that big, scary ‘real world.’

Here is one of the more reverent official answers:

“Publicly engaged academic work is scholarly or creative activity integral to a faculty member’s academic area. It encompasses different forms of making knowledge ‘about, for, and with’ diverse publics and communities. Through a coherent, purposeful sequence of activities, it contributes to the public good and yields artifacts of public and intellectual value.” (From: Ellison, J., and T. K. Eatman. 2008. Scholarship in Public: Knowledge Creation and Tenure Policy in the Engaged University. Syracuse, NY: Imagining America.)

The photo above is of me looking very happy yesterday at the University of Washington Odegaard Library (first floor) in front of my public scholarship multimedia exhibition Soul Stories: Homeless Journeys Told Through Feet.
This is a collection of poetry, prose, photographs, and digital storytelling videos about my work as a nurse providing health care to people marginalized by poverty and homelessness. I understand homelessness at a visceral level, having lived through it myself as a young adult. I also readily acknowledge that just because I ‘made it out of homelessness’ doesn’t mean everyone can, nor that it is an easy thing to do, especially within our society.

The Soul Stories exhibition will be at Odegaard Library (opposite Suzzallo Library on ‘Red Square’) through March 20, 2015. Odegaard Library is open to the public during regular library hours. Many thanks to the wonderful librarians at Odegaard who opened this space for me, and thanks to 4Culture for helping to fund part of this project. I was looking happy in this photograph because this has been the most challenging, fun, and soul-satisfying scholarly project so far in my career.

Public or community-engaged scholarship has never been valued by ‘high brow’ university types, especially not at research-intensive universities. It generally doesn’t ‘count’ as a valid activity for those pursuing graduate degrees. It generally doesn’t get you tenure. But that all seems to be changing, albeit at the achingly slow speed of any change within higher education. The catalyst for this change seems to be less from sudden altruistic enlightenment on the part of the academy, and more from public pressure for universities to show tangible positive impact at the local, national, and international levels. Within medical science scholarship, you can see this outside pressure manifested in the embrace of ‘translational research.’ Research within the realm of public scholarship doesn’t need to be translated.

Within the area of health-related public scholarship, a terrific resource I have used throughout my career is the Community-Campus Partnerships for Health (CCPH).  Check out the free, no membership required resources on their website, especially CES4Health, for peer-reviewed products of community-engaged scholarship.

Virginia Relics Part One: Racism

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Virginia State Capitol, Richmond 2014/Josephine Ensign

Health and Homelessness in Richmond, Virginia in the 1980s: My hometown of Richmond, Virginia is a city anchored to its past by bronze and marble Confederate shrines of memory, by an undying devotion to the cult of the Lost Cause. I was born and raised in the furrowed, relic-strewn Civil War battlefields on the city’s tattered eastern edge. A captive of its public schools, I was taught official Virginia history from textbooks approved by the First Families of Virginia. But I came to understand the shadowed history of my state by caring for its homeless outcasts.

These lessons began while I was in nursing school in the early 1980s. The modern hospital of the Medical College of Virginia curled around the former White House of the Confederacy like a lover. My clinical rotations were nearby in the crumbling brick former Colored Only hospital, which then housed indigent and homeless patients, as well as prisoners. Most of these patients were black, so I called it (to myself) the Almost Colored Only Hospital. The prisoners, shackled to their beds and accompanied by brown-clad armed guards, were from the State Penitentiary located across town. One of my patients was a Death Row inmate. When I spoon-fed him his medications, I was simultaneously afraid for my own safety and ashamed of being an accomplice to murder. I knew I was nursing him back to health only to return him so he could be killed by the state. I also knew this was not something I could discuss with my oh-so-white clinical nursing instructor. Racism was never addressed in nursing school.

One evening in 1985, during my final year of nursing school, I was on Belvidere Street driving home from a clinical day on the south side of Richmond. At a stoplight I found myself surrounded by a crowd of scruffy white men. Some of them thrust hand-lettered cardboard signs towards my car, and chanted, “Kill the N—er!” as I drove past the Virginia State Penitentiary. On the other side of Spring Street stood a smaller crowd of people holding lit candles and singing hymns. I had been following the local news, so I knew what the protests were about. I just didn’t know they would spill out into the street—that I would be forced to see and hear them. I also didn’t realize how racist and hate-filled they’d be. That part was politely–conveniently– left out of local news.

That evening, June 25th, 1985, Virginia electrocuted Morris Mason, a thirty-two-year-old black man from the isolated, rural Eastern Shore of Virginia. Mr. Mason admitted to killing a white woman, waived his right to a trial, and was sentenced to death by a white judge. With an IQ of sixty-six, Morris Mason had the mental functioning of an eight year old. He also had paranoid schizophrenia, diagnosed during a brief stint in the Army. He’d been unable to get treatment after he was discharged. So Virginia was executing a mentally retarded and mentally ill man who had never stood trial for murder.

Virginia holds the dubious distinction of being the state with the most executions in its history, and maintains the highest per capita rate of executions in the country. Those executed in Virginia—as elsewhere in the South—are disproportionately poor and black, and typically have been charged by white judges with murder of white people.

The Richmond Street Center was located in the armpit of town, near the impoverished and racist all-white Oregon Hill, and across the Downtown Expressway from the State Penitentiary. During my years working at the Street Center, four more men were executed next door—one every year—usually during the hottest part of summer. All of the men were killed at night by electrocution with two 2,200-watt surges of electricity. Most of the men were killed in the months leading up to local elections. Politicians used the executions as evidence of being tough on crime. The death penalty did nothing to deter crime: Richmond continued to have one of the highest murder rates in the country. Murder rates everywhere in the world are directly linked with socio-economic and racial inequities–as well as to access to handguns.

Before the executions, my patients would joke about how the lights would dim in the area around the State Pen when anyone was electrocuted. They also teased me about the chair I had in my office. It was a 1930s era white enameled iron exam chair, donated by owners of an employee’s clinic at a Richmond tobacco processing plant that had recently closed. The arms of the chair swiveled. It had a padded, adjustable metal clamp headrest. The chair had been designed for ear, nose and throat exams. I had it in my office because it was handy to use for taking vital signs and for blood draws. Patients would often sit in it, place their heads back in the metal headrest, flap the chair arms back and forth, and call it Old Sparky. It was mostly white men who joked about the executions. Sometimes the Street Center took on a carnival atmosphere in the days before an execution. I chalked that up to remnants of racism and to the collective memory of lynchings.

Virginia’s Racial Integrity Act of 1924 was an anti-miscegenation law spearheaded by Dr. Walter Plecker, a white supremacist male physician and public health professional, who was head of Virginia’s Bureau of Vital Statistics, a division of the Virginia State Board of Health. The law mandated that a racial description of every person be recorded at birth, with babies sorted into one of two categories: white or colored (black or American Indian or anything else non-white), following the one-drop rule. They added the ‘Pocahontas Exception’ since many of Virginia’s first families claimed descent from her—so Virginians could be white if they had no more than 1/16th American Indian blood. The Racial Integrity Act wasn’t overturned until 1967.

When I think about my hometown of Richmond, Virginia (and when I revisit the city as I did this week), it makes me sad—and angry—that it continues to have the worst health statistics of any place in Virginia. The population is majority African American, and it has wide income inequities, along with all the social ills that accompany it, including homelessness. While Virginia ranks in the top ten nationally for per capita income, it has one of the lowest minimum wages and one of the worst Medicaid and state children’s health insurance coverage rates in the country. The Republican-controlled General Assembly has continued to block efforts to add ACA/healthcare reform Medicaid Expansion services (see NYT article linked below). Virginia ranks towards the bottom nationally in provision of mental health care services. Virginia has a deeply rooted history of bias against mental illness, mental retardation and developmental delay. In the wake of the Virginia Tech shootings in 2007, Virginia’s politicians were pressured to work towards improving the state’s mental health system, but they have a long way to go. They also have a long way to go in acknowledging and redressing the deep wounds of institutionalized racism.

**Resources: