The Future of Nursing

Lillian Wald’s public health nurse uniform

The future of nursing should begin with people and community/population health. And to do that we need to disrupt our tired, outdated approach to nurse education. Not by tweaking here and there. Not by investing tons of money in yet more high tech simulation labs and “dummies.” Not by asking ourselves and our students, “What would Florence do?” (as in the Florence Nightingale, important as she is). Rather, we should begin by asking, “What would Dorothea do?” (as in Dorothea Dix, US and international mental health reformer) and “What would Lillian do? (as in Lillian Wald, the “mother of public health nursing” and founder of the Henry Street Settlement House in New York City).

“Begin with people, not body parts,” is what one of our nursing students told us recently when she heard that we are disrupting our pre-licensure nursing program at the University of Washington. Starting this coming academic year (begins in September), we will begin with people—with community, public health nursing instead of the longstanding “traditional” acute care medical-surgical nursing. I am excited to be teaching this “new” community/public health nursing course. It will begin at the true beginning with the social determinants of health equity. Not just with the social determinants of health (SDH)—those factors that affect our health from where we live, work and play. The social determinants of health equity extends past the SDH to acknowledge and address the inequities inherent in our society that affect health, including structural racism, and all the other “isms” of longstanding discrimination against women, persons of color, LGBTQ people, disabled folks, and the aged. Dr. Camara Jones and her “Cliff of Good Health” is the best illustration of this.

The Future of Medicine 2030 Seattle Town Hall was held at the University of Washington this morning. This builds on and extends the work of the Institute of Medicine’s Future of Nursing report back in 2010. The theme of today’s town hall meeting was “High Tech, High Touch.” I was dismayed (okay, I was irritated) that the lead speaker at today’s event was a physician, Molly Coye, who is an executive-in residence with AVIA, a network of US health systems “solving problems with digital technologies.” It is the “The Future of Nursing” after all and not “The Future of Our Insanely Expensive and Ineffective US Healthcare System.” And it should be led by nurses!

The one truly inspirational speaker at today’s event was a nurse—Dean Kenya Beard from Nassau Community College in New York. She spoke of some of the drawbacks of health technology and how they can amplify health inequities and how most of the proprietary algorithms for high tech “solutions” lack transparency. She called out the pressing need for nurse educators to “rise above any level of discomfort” and address structural racism and interventions that work. As to structural racism in our country she stated, “humans created it and only humans can destroy it.” She ended her talk with, “We need daring ingenuity.”

My question/comment which I posted online during the town hall was this:

“Why aren’t we using the much more useful term “social determinants of health equity” versus the rather status quo term “social determinants of health”? Why aren’t we killing forever the outdated and unhelpful message to our nursing students that they “have to have at least two years of inpatient med-surg” work before they go on (yes, go on) to community, public/population health nursing? Why aren’t we stopping the practice of educating nursing students to be “agents of social control” and instead to be “agents of social change?” Also, thanks for the refreshingly honest and necessary presentation and perspective from Kenya—Brava!

Yes, Virginia, Slavery Was Real

And yes, Virginia, your deeply entrenched legacy of racism is showing. It is ugly and the way you are addressing it (I’m talking to you, Governor Northam) is exasperating and shameful.

I am a Virginian. I was born and raised in Richmond, Virginia; was (moderately) educated in its Hanover County public schools (Battlefield Park Elementary School, Stonewall Jackson Junior High School, and Lee Davis High School—need I say more?); and, I received my nursing degree from the Medical College of Virginia. Oh yes, and I was married and had my son there. I was a Virginia resident for the first thirty years of my life. I worked with former white (and blatantly racist) classmates of Governor Northam.

This past week I have had colleagues and even (non-Virginian) family members ask me if this whole “blackface and KKK garb” at college/medical school parties and even in yearbooks was really that widespread in the 1980s. Of course it was. Does that make it okay? Of course not. Everyone knew how hateful and racist it was.

Governor Northam is showing his true white male supremacist color in how he is handling the ‘outing’ of the blackface/KKK garb photo on his medical school yearbook page. Promising to read Ta-Nehisi Coates, as if that will provide the ‘magical negro’ cure for his own racism? Digging his heels in (because he can) and proclaiming, “I’m not going anywhere” and that he “has grown” over the past week of controversy? How he is acting now is the true measure of the man—and of the state of racism in our country.

History—Not Was, But Is

DSC00528History is not was, it is. This pithy and prophetic statement is attributed to the quintessential white Southern writer, William Faulkner. Having read most all of his novels and short stories, this sounds like something he would say. And I label the statement prophetic because to not understand and heed these wise words—which he had to have said pre Civil Rights era—contributes to the problems that plague our country today.

I have written extensively about my own upbringing and deep roots in the American South, including being raised at the South’s first racially integrated children’s summer camp in KKK country, on land scarred by slavery and the Cold Harbor, Virginia battles of the Civil War. On my father’s side, I am related by blood to Varina Davis, First Lady of the Confederacy, wife of Jefferson Davis, who was President of the Confederate States of America. I went to Battlefield Park Elementary School, Stonewall Jackson Junior High School, and Lee Davis High School (The Rebels as school mascot) and I was fed a continuous stream of misinformation and historical revisionism at this string of public schools. A high school classmate was the son of the Grand Dragon of the regional KKK and I received assault/death threats from him (conveyed through my Biology teacher to my parents) when I campaigned for Jimmy Carter. I knew that the Civil War was very much alive and unwell.

It still is. And not just in the American South. White supremacist hate groups exist throughout the U.S. and have grown in strength and number and venom. They are invited by Republican student groups to our college campuses. They actively recruit on and around college campuses and high schools, as well as through social media. For a deeply disturbing and important recent Propublica video report on this see “Inside the Secret Chat Logs of American Nazis.”  The Seattle Times recently published an article by Jim Brunner, “Report: Washington State home to one of the largest cells of notorious white supremacist group” (February 23, 2018). Resistance to hate is not passive, it is active.

In the words of Barbara J. Fields, professor of American History at Columbia University:

“I think what we need to remember most of all is that the Civil War is not over until we today have done our part in fighting it, as well as understanding what happened when the Civil War generation fought it. William Faulkner once said that history is, not was—it’s is and what we need to remember about the Civil War is that the Civil War is in the present as well as in the past. The generation that fought the war, the generation that argued over the definition of the war, the generation that had to pay the price in blood, that had to pay the price in blasted hopes and lost futures, also established a standard that will not mean anything until we have finished the work.

You can say that there is no such thing as slavery anymore—we’re all citizens–but if we’re all citizens then we have a task to do to make sure that it is not a joke. If some citizens live in houses and others live on the street, then the Civil War is still going on, it is still to be fought, and regrettably, it can still be lost.” (From the Ken Burns PBS series The Civil War, episode nine.)

Southern Shrines of (Racist) Memory

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Statue of Jefferson Davis, Monument Avenue, Richmond, Virginia. Photo credit: Josephine Ensign/2009

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. The modern hospital of MCV 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 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 wanted to talk to him, ask about his family, about his life in and outside of prison, but the stone-faced armed guard loomed over me. I knew from experience not to discuss my ambivalent feelings with my nursing instructor. She considered these to be inappropriate topics. I wanted to finish nursing school as fast as I could, so I kept silent. (From the chapter “Relics” in Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net, pp. 57-58).

 

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White House of the Confederacy (right) and Medical College of Virginia (now VCU) Hospital. Photo credit: Josephine Ensign/2009

These words—my own words— have come back to me this week as I followed the news of contested sites of memory, of whitewashed Civil War memorials literally being fought over once again in places like New Orleans and Charlottesville, Virginia—and perhaps soon in my hometown of Richmond, Virginia. In Charlottesville, white nationalists waved lit torches and chanted “You will not replace us” in front of a statue of General Robert E. Lee in a city park. (source: Associated Press, Washington Post, “Torch-wielding group protests Confederate statue removal” May 14, 2017). New Orleans has begun the removal of four Confederate monuments in the city, starting with the Battle of Liberty Place monument commemorating the Crescent City While League’s violent fight against desegregation of the city’s police force—in 1876 during Reconstruction. (source: Christopher Mele, New York Times, “New Orleans Begins Removing Confederate Monument, Under Police Guard” April 24, 2017).

Richmond, as the former Capital of the Confederacy, likely has the largest collection of statues to Confederate “war heroes” of any city. I took my driver’s test on the then still cobblestoned streets of Monument Avenue, a five-mile long stretch of tree-lined divided grand boulevard punctuated by traffic circles around five towering statues of civil war heroes. A sixth and very controversial statue was added in 1996 at the far western end of the avenue—of native Richmonder Arthur Ashe (1943-1993). Besides being an international tennis star, Ashe was also a civil rights and HIV/AIDS activist, and a champion of urban health equity work. His memorial statue on Monument Avenue portrays him standing, holding books in one hand (he was also an excellent student and UCLA college graduate) and a tennis racket in the other hand. In the statue, he faces west, away from the Confederate statues. When Ashe was growing up in segregated Richmond, he was barred from playing tennis in the city’s whites only parks—and, ironically, he also would have been barred from even walking down Monument Avenue, a whites only residential area.

Since Monument Avenue in Richmond is a designated national park and indeed, is the only national park to consist of city street, it is unlikely that any of the Confederate statues will be removed anytime soon. But perhaps it is time to rename the street Memorial Avenue. This idea comes from University of Richmond professor of philosophy Gary Shapiro in his NYT opinion page essay “The Meaning of Our Confederate ‘Monuments'” (May 15th, 2017). Shapiro points out that records of city planners of the Confederate “war hero” statues on what would become Monument Avenue, “show that they meant to legitimize and dignify the white supremacist regime that had taken hold in Virginia.” He quotes philosopher of art Arthur Danto who states, “We erect monuments so that we shall always remember, and build memorials so that we shall never forget.”

Instructive and remarkably prescient here are words of Henry James, in his travelogue book The American Scene, in the chapter “Richmond” about his visit to Richmond in the late winter of 1905. A late snowstorm prevented him from traveling very far from the center of Richmond, but he describes his walk to the then newly developing Monument Avenue and the statue of Robert E. Lee (erected in 1890). James reflects on his visit to Richmond and writes:

“History, the history of everything, would be written ad usum Delphini—the Dauphin being in this case the budding Southern mind. This meant a general and a permanent quarantine; meant the eternal bowdlerization of books and journals; meant in fine all literature and all art on an expurgatory index. It meant, still further, an active and ardent propaganda; the reorganization of the school, the college, the university in the interest in the new criticism.” p. 374 Henry James, The American Scene (London: Chapman and Hall, Ltd).

My own then budding Southern mind, educated in the Virginia public schools of Battlefield Park (named for the Civil War Battle of Cold Harbor) Elementary School, Stonewall-Jackson Junior High School, Lee-Davis High School—and then VCU/MCV nursing school—was negatively affected by that still-lingering, ardent, white supremacist propaganda. Through my father I am related to Varina Davis, First Lady of the Confederacy. That legacy, and the work that I have done and continue to do to actively resist racism, is something I do not want to forget.

Body, Soul, Survival

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University of Washington, Seattle. Photo credit: Josephine Ensign/2017

“Health is politics by other means,” asserts Columbia University professor of sociology Alondra Nelson in her fascinating book Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination (Minneapolis: University of Minnesota Press, 2011). Nelson acknowledges that her statement is inspired by French philosopher and scientist Bruno Latour’s assertion that science is politics by other means. For anyone who ever doubted either of these assertions—or thought they were alternative facts—you must live in the Land of Narnia.

Before reading Nelson’s book I knew that Black Panther Party for Self Defense had created community-based primary care health clinics in many major U.S. urban areas in the late 1960s/early 1970s. But I did not understand the true breadth of their healthcare activism. I worked as a nurse practitioner for about six years at Seattle’s Carolyn Downs Family Medical Clinic , originally formed in 1968 as a Black Panther clinic. It is located in the Central District of Seattle, a traditionally black neighborhood that is now significantly gentrifying. It is named after an early Black Panther community organizer, Carolyn Downs, who died at an early age of breast cancer—something that most likely could have been detected and more effectively treated if she had had better access to the primary care now provided by the clinic she helped develop. A highlight for me of working at Carolyn Downs Clinic was being able to care for one of Carolyn’s granddaughters.

The Black Panther Party for Self Defense was formed in Oakland in 1966 as a survival tactic “to afford protection for poor blacks from police brutality and to offer varied other services to these same communities.” (pp. 5-6) These services included the establishment of no-cost community-based primary care clinics, sickle-cell and blood pressure screenings, free breakfast programs for children, and after-school and summer tutoring programs. They also formed teams of patient advocates who accompanied their patients to hospitals or specialty care, heralding our current system of patient navigators. The Black Panthers were also instrumental in challenging the formation of the Center for the Study and Reduction of Violence at UCLA, a research center backed by the California governor Ronald Reagan, and which promised to find the origins of violence. It was to be headed by psychiatrist Louis Jolyon West, whose previous research included experiments with sleep deprivation, LSD, and correlating the era’s student activism with antisocial behavior. (pp. 153-154) The Black Panthers contended that aggression for people within marginalized communities was a legitimate response to oppression. They, along with many other activists, were successful in blocking funding for this center.

The American Journal of Public Health (AJPH) dedicated its entire October 2016 special edition issue to the public health work and legacies of the Black Panther Party. As physician and AJPH editor-in-chief Alfredo Morabia writes:

“Now that a new generation is carrying on the ideals of the health activists of the 1960s, it is time to revisit this history, understand the strengths and weaknesses of the BPP public health initiatives, and have a frank debate about what really happened. The stakes are huge for an emerging generation unwilling to accept that certain lives matter less than others, and that, as the recent massive lead contamination of the Flint, Michigan, water system shows, many poor (and Black) communities still remain defenseless against such overtly aggressive assaults to their health in a context in which, as Angus Deaton puts it, the infamous one percent is not only richer but much healthier.”

Read more in this AJPH special issue: http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303405

Additional resources:

The Seattle Black Panther Party History and Memory Project, part of the University of Washington’s Seattle’s Civil Rights and Labor History Project, led by UW professor of history James Gregory—contains videotaped oral histories, historical photographs and news coverage and more.

 

Beyond Violence: End With Responsibility

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“Face of the Abyss” Josephine Ensign, Mixed-media on canvas, 2015.

“We begin a poem
with longing
and end with
responsibility

And laugh
all through the storms
that are bound
to come

We have umbrellas
We have boots
We have each
other”

~Excerpt from Nikki Giovanni’s poem “Where Do You Enter.”

And from Attorney General Loretta Lynch : “This has been a week of profound grief and heartbreaking loss. After the events of this week, Americans across our country are feeling a sense of helplessness, of uncertainty and of fear. We must reject the easy impulses of bitterness and rancor and embrace the difficult work — but the important work, the vital work — of finding a path forward together.” (As quoted in the NYT article “Shootings Further Divide a Nation Torn Over Race” by Timothy Williams and Michael Wines, July 8, 2016.)

Last night, as the many peaceful protests occurred in cities around the country over the latest police killings of African-American people (Alton Sterling in Baton Rouge and Philando Castile in Minnesota), I finished reading Ta-Nehisi Coates’ memoir The Beautiful Struggle (New York: Spiegel and Grau, 2008). Coates has been called the ‘angry black man of choice for progressive-type white people,’ and perhaps there is some truth to that quip. His writing manages to be angry but not bitter, highly educated while somehow sounding more authentically gritty.

The Beautiful Struggle is almost a love letter to his father, W. Paul Coates, a former Black Panther, and the founder of the Black Classic Press. Coates’ more recent book, also a memoir of sorts–but one written as a love letter to his own son-(and a much stronger book in my opinion), is Between the World and Me (New York: Spiegel and Grau, 2015). As I look at these two books of his lying side-by-side on my desk, I realize the covers of both (as well as of the hardback edition of The Beautiful Struggle) are black and white and red. A classic and powerful color combination, but also one that today, as the violence and killings of not only African-Americans but also of the Dallas police officers continues and just seems to escalate, black and white and red takes on a new—and gruesome—visual meaning.

“Hate gives identity.(…) We name the hated strangers and are thus confirmed in the tribe.” (Coates, Between the World and Me, p. 60.) But, as hippy-dippy and starry-eyed as it might sound, doesn’t love also give identity? And if we begin to name the loved strangers, don the boots to walk through muck on that path forward, perhaps we get beyond violence and despair. End with responsibility: individually, tribally, nationally.

Who Will Tell the Story?

DSC00528“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 battle fields 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 outcasts.

These lessons began while I was in nursing school. 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 the almost-colored-only hospital. The prisoners, shackled to their beds and accompanied by brown-clad 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 to be killed by the state. I wanted to talk to him, ask about his family, about his life in and outside of prison, but the stone-faced armed guard loomed over me. I knew from experience not to discuss my ambivalent feelings with my  nursing instructor. She considered these to be inappropriate topics. I wanted to finish nursing school as fast as I could, so I kept silent.” (pp. 57-58, from my forthcoming medical memoir Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net, Berkeley: She Writes Press, August 9, 2016.)

I was reminded of this passage from my book this past week as I read the NYT article “Who Will Tell the Story of Slavery?” (Lorne Manly, June 29, 2016). Manly describes the (sadly to me, oh so familiar) political dueling going on in my hometown of Richmond over the location of the National Slavery Museum. Former Virginia governor L. Douglas Wilder (our nation’s first elected African-American governor, who was more recently also the Mayor of Richmond (2005-9), wants to establish the museum in the former First African Church (now owned by the Medical College of Virginia/Virginia Commonwealth University and located next to the main hospital I describe above). But the current powers-that-be, including the current Mayor Dwight C. Jones, want to locate such a museum at the historic site of the notorious Lumpkin’s Jail, a former slave prison, dubbed ‘The Devil’s Half-acre,’ the site of which was recently located and excavated. (see the Smithsonian Magazine article “Digging Up the Past at a Richmond Jail,” by Abigail Tucker, March 2009.)

The Richmond indie bookstore, Fountain Bookstore, where I’ll be doing a Catching Homelessness author event (Tuesday October 11, 2016 at 6:30 p.m.), is located a few blocks from the site of the former slave prison in the Shockoe Bottom area of Richmond. Perhaps I’ll include a reading of this section of my book. And not keep silent anymore…