“BE uncomfortable. That’s how you learn!” was one of the final exhortations to our students by Pepe Sapolu Reweti at the conclusion of our”Empowering Healthy Communities” study abroad in New Zealand program this past summer. She was describing the fact that there are many Pakehas (‘white’/European descent New Zealanders) who do not personally know any Maori people, much less ever been on a Maori marae (‘meeting place’ similar to our U.S. Indian ‘reservation’ except that it is the ancestral home of the Maori iwi, or tribes), much much less ever have been in a Maori home. She pointed out that our students had all been on a marae (several, in fact) and had been inside a Maori community meeting house, and had shared ‘kai’ (a meal–several, in fact). That’s an honor and a privilege and something for us to learn from, to take back home–to apply in our own country, in our own daily lives. If the students learned nothing else from this study abroad experience, I hope they learned this.
I was reminded of Pepe’s words this past week as I listened to Ta-Nehisi Coates talk about his latest book Between the World and Me, written in the form of a letter to his son about being a black man in the deeply scarred and racist modern day America. His talk was in the sold-out 2,900 seat McCaw Hall at the Seattle Center, as part of the Seattle Arts and Lectures literary series. The interviewer asked Coates about his article “The Case for Reparations” in the June 2014 edition of The Atlantic, and why he thought it had ‘gone viral’ and been so popular among white people. He replied that he thinks people like the fact he doesn’t sugar-coat things, that “It’s a sign of respect the way I talk directly about things.” And he added, “Reality is uncomfortable. Period.”
Looking around the packed auditorium in one of the whitest cities in America, I wondered how many of us white audience members were now wallowing in white guilt: white guilt which is itself a white self-indulgent privilege. How many of us white Seattleite audience members are willing to push past white guilt to do anything constructive to confront racism in our country, in our city, in our neighborhood, in our own homes? And what are we as health care educators doing to ‘teach meaningfully to’ the effects of personally-mediated and institutionalized racism?
“…as Americans we are so heavily invested in shame, avoidance, and denial that most of us have never experienced authentic, face-to-face dialogue about race at all.” (“To Whom It May Concern” by Jess Row in The Racial Imaginary: Writers on Race in the Life of the Mindedited by Claudia Rankine, Beth Loffreda, and Maxine King Cap, Fence Books 2015, p. 63.) In this same essay, Row states she once saw a book on classroom management for college teachers with the title When Race Breaks Out. “As if it’s like strep throat, as if it has to be medicated, managed, healed.” (p62.)
We need to allow ourselves–and our students–to be uncomfortable, to confront uncomfortable truths in order to learn any lessons that are worth learning.
Our UW Health Sciences Common Book this year is Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Time of Colorblindness (The New Press, 2010). This is the fourth year we have had a UW Health Sciences Common Book, with interprofessional activities based on the book’s theme interspersed throughout the academic year. Previous books have been Anne Fadiman’s The Spirit Catches You and You Fall Down (a classic if not a bit ‘overdone’ by now), Gabor Mate’s In the Realm of the Hungry Ghosts: Close Encounters with Addiction (great topic but his book is in need of heavy editing–he rambles), and last year’s book was Seth Holmes’ Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States (great topic but read like a doctoral dissertation–which it was). The New Jim Crow is written in an accessible, non-academic and powerful style, and is, of course, on a painfully current topic in the U.S. and one pertinent to health care inequities: racism.
Dr. Danielson started his talk by acknowledging the history of the Central District where he works, and the ‘strong black women,’ of the neighborhood’s past, Odessa Brown and Carolyn Downs, for whom the two community clinics are named after. Both women advocated for quality and accessible health care for their communities. Odessa Brown, who had experienced racial discrimination in accessing health care, was active in starting a children’s clinic in the Central District before she died at age 49 of leukemia. Kudos to the Odessa Brown Children’s Clinic for including information on Odessa Brown (the woman) on their front webpage, in ‘Our History,’ right under ‘Our Mission.’
Carolyn Downs was part of the Seattle Black Panther movement, who with the financial help from people like Jimi Hendrix and James Brown (both from the Central District), in 1968 opened what was then the first health clinic in the community. Less of her history is included on the webpage for the clinic, but I know from having worked there and taking care of the daughter and granddaughter of Carolyn Downs, that she died young of breast cancer–and at least partially because of disparities in access to breast cancer screening and treatment.
I provide some of the history of both Odessa Brown and Carolyn Downs because I admire the work they did during their too-short lives, and because–as Dr. Danielson said in his speech–this can become another example of “black people being deleted from history.”
What to do about the continued, pervasive, and destructive problem of racism in our society, including in our institutions ranging from prisons to hospitals and clinics? The main message from Dr. Danielson and Michelle Alexander (through her book) is that it will take both individual and collective action for us (for the U.S.) to create positive change. During his talk, Dr. Danielson spoke of using the companion community organizing guide to The New Jim Crow, titled Building a Movement to End the New Jim Crow: An Organizing Guide by Daniel Hunter (Veterans of Hope Project, 2015).
In chapter one of this guide, “Roles in Movement-Building,” Hunter references the terminology used by Bill Moyer in his book Doing Democracy: The MAP Model for Organizing Social Movements (New Society Publishers, 2001) This work divides people’s roles into four main groups: 1) Helpers–direct service providers, 2) Advocates-who work to make systems work better for those in need, 3) Organizers–who bring people together to change systems, and 4) Rebels–who speak truth to power and agitate for radical change. The key is to recognize our own strengths and roles–where we are most comfortable working– but also to see the value in the rage of roles played by different people, because an effective social change movement requires people working in all of these roles.
This is similar to the “Bridging the Gap Between Service, Activism, and Politics” group activity from the Bonner training curriculum that I have used for many years when teaching community health. But (of course!) I like the addition of the category ‘Rebels’ to the mix and plan to add that the next time I use this in teaching.
On a very sobering (as if we weren’t already very sober) note, Dr. Danielson ended his talk Tuesday night by adding that for all the good work and innovative community outreach programs of the Odessa Brown Clinic, he often asks himself if they aren’t keeping children healthy enough that they too can end up in our country’s prison system.
“Art is the outward manifestation of human experience in the world. Art is necessary for survival. To be human and alive is to be an active art maker. Everything that humans create in their act of living is art.” -Tamati Patuwai, MAD AVE ‘Healthy and Thriving Communities’ Glen Innes, New Zealand
It was a happy accident, an unintended yet very welcome consequence of studying ‘how the Kiwis’ do community health from the ground (literally) up, from the community members’ perspectives. The recent experience has changed how I think about community health, has deepened my respect for the power of art (and libraries) to change lives, and has even altered how I view my own community back home in Seattle.
First, a brief recap of the experience to provide some perspective. What I’m referring to here is the recent University of Washington Study Abroad in New Zealand 5-week immersive program I co-led with Jim Diers, a social worker and internationally-acclaimed community development expert. Here is what our course description said about the study abroad program:
“Empowering Healthy Communities is an interdisciplinary Exploration Seminar in New Zealand, focusing on how various communities organize and advocate for overall health and wellbeing. In this seminar, we will combine community-engaged service-learning, community case studies, readings, reflective writing, student independent projects, and immersive living experiences, to challenge students to think more broadly and creatively about participatory democracy, civic engagement, sustainability, and the social determinants of health. This course is grounded in an international, community-engaged, service-learning format aimed at creating opportunities for transformational student learning. We will address the meanings of ‘diversity’ within global and local communities; issues of power and privilege; social justice; what it means to be civically engaged at the local and global levels; and the tensions and differences between tourism vs. travel, and community service vs. engagement.
New Zealand is an ideal location for this Exploration Seminar. The country has a unique blend of indigenous and immigrant cultures, and its people have a rugged, “number eight wire” can-do, and highly creative approach to solving individual and community problems. In 2014, New Zealand ranked number one in the Harvard Business School’s Social Progress Index for overall wellbeing, while the U.S. ranked number sixteen, just above Slovenia. New Zealand spends one-third less per person on health care than we do in the U.S., yet they have much better population health outcomes. How do they do it? That is one of the main questions we will ask and explore through our work and study in New Zealand. In addition, as New Zealand is a world leader in environmental sustainability efforts, we will challenge ourselves to go ‘as green’ as possible: living in youth hostels, recycling, walking and taking public transportation, and eating a mainly vegetarian diet for our group meals.”
As we discussed with the students at the beginning of our program, New Zealand slipped somewhat in the 2015 Social Progress Index, but is still in the top tier/top ten of the 133 countries with sufficient comparison data to include. In 2015 for the ‘Health and Wellness’ category, New Zealand ranked 9th and the U.S. ranked 68th. And somewhat ironically in light of our study abroad program, the U.S. ranks first world-wide in the Access to Advanced Education category, and is weakest in Health and Wellness and Ecosystem Sustainability. I tried to remind students of this fact, especially when some of them grumbled about the vegetarian meals and relying on public transportation.
Using connections through the amazing New-Zealand group Inspiring Communities, we focused our time on a variety of local community groups working to empower and improve the places they call home. The Central Business District/ Karangahape Road in Auckland. The Avondale and Henderson communities on the outskirts of Auckland. Devonport and Waiheke Island, both more affluent communities. The Ruapotaka marae in Glen Innes. Then south to the Wellington area communities of Porirua, Bromphore School, and Epuni. Consistent through all of these communities was an emphasis the community members placed on the use of the arts to catalyze positive change and to enable community wellbeing. That and public libraries, which community members treasured as being the heart and soul and ‘mind food’ of their communities. Places where true democracy happens. Places to “dream up and enact crazy ideas.” Places that nurture “the freedom to change.”
Art, including literary art, was literally everywhere we turned in these communities. And not just the typical government-sanctioned commissioned public art we are used to seeing in the U.S., but also much more grassroots , low barrier, “anybody can participate” community art shown in my photos in this post.
This sort of art not only beautified the communities, it also built community identity and promoted wellbeing. Walking around my hometown of Seattle this past week, I’ve been searching for similar sparks of community wellbeing through art and have had a hard time finding them. Yes, we do have some great bus shelter artwork, as well as some building and wall murals–and our public library system has been one of the best in the country (and hopefully will remain so despite a very silly rebranding effort), but I cannot find the same level of empowering healthy communities through art. Perhaps this is an important ‘take home’ message, one we could use to improve community health and wellbeing in the U.S. More art, less guns.
This week’s New Yorker article by Kathryn Schulz, “The Really Big One”, about my beloved Pacific Northwest’s vulnerability to a devastating mega-earthquake and tsunami, has stirred a lot of debate and fear here in my hometown of Seattle. There’s been a run on the buying of ready-made disaster preparedness kits. Companies doing seismic retrofitting of houses are now booked out almost a year. As the article states, scientists report that we are overdue for a large or mega earthquake (9,0) and tsunami (100-ft) that will kill at least 13,000 people, injure 27,000, displace 1 million people, and destroy two-thirds of all hospitals. Everything west of Interstate 5 will be destroyed.
Currently, despite having the technology to install a sophisticated early-warning earthquake system, we don’t have one and we will have to rely on the “cacophony of barking dogs” to provide us with a 30-90 second warning before the ‘real quake’ hits. (Dogs can hear the high-frequency compression waves that precede an earthquake. Yet another reason to love dogs.)
It is clear that our government entities, businesses, hospitals, schools, fire departments, need to do much more to prepare for this disaster. As individuals we can support legislation to require better community-wide disaster preparedness (and support ways to actually fund these measures). As individuals we can heed the public health disaster preparedness advice and keep adequate disaster kits in our homes, school, and worksites. In a previous blog post titled “Be Very Afraid” (November 22, 2014) I wrote: “Or be at least a little bit afraid: not so afraid that you become paralyzed with fear and not so little afraid that you don’t do practical things to better prepare yourself (and your family) in case of disaster/emergency. Aim for being ‘just right’ afraid.” And I recorded the items I collected to make our family’s disaster/emergency preparedness kit–along with the realization that disaster preparedness is not an equal opportunity affair.
But something I have learned from my colleagues in New Zealand who work on post-Christchurch earthquake recovery efforts, is that an equally important part of disaster preparedness at the community level is promoting community resilience and wellbeing. More closely-knit communities–regardless of economic resources–tend to weather disasters better than others. Several of the Christchurch-area Maori marae (communal, sacred land/communities) organized to take in and provide food and shelter for foreign students and visitors affected by the earthquakes before any official government-sponsored program was able to do that. This isn’t to gloss over the very real socio-economic and racial disparities highlighted by ‘natural’ and man-made disasters. The lessons on this from Hurricane Katrina in New Orleans stand as reminders.
I was somewhat skeptical when I first encountered these bright, up-with-people banners (shown in the photo above) I saw in the midst of the still fresh earthquake devastation in the downtown core of Christchurch in 2014. But as I focused more on their messages, I realized they were all about building individual and community resilience. They are part of the All Right? Campaign, a Healthy Christchurch initiative of the Canterbury District Health Board and the Mental Health Foundation of New Zealand. They based their campaign on the work of the UK-based social, economic, and environmental justice think tank, The New Economic Foundation, which developed the evidence-based Five Ways to Wellbeing (with a Kiwi slant below). Now these are some excellent ways to prepare for the Big One.
Connect… With the people around you. With whanau, friends, colleagues and neighbours. At home, work, school, or in your local marae, church or community. Think of these connections/relationships as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.
Be active… Exercising can make you feel good! Step outside. Go for a walk or run. Cycle. Play a game. Garden. Have a boogie or do some kapahaka. The most important thing is to find a physical activity you enjoy that suits your mobility and fitness. Do it with friends or whanau and you’ll be ticking two boxes… connect and be active!
Take notice… Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.
Keep learning… Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn Te Reo or how to play an instrument or cook your favourite food. Set a challenge you enjoy achieving. Learning new things will make you more confident as well as being fun.
Give … Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, as linked to the wider community can be incredibly rewarding and creates connections with the people around you. Aroha ki te tangata, a Maori saying meaning respect for/goodwill towards others.
This week I have been immersed in both the history and present state of the health care safety net in my home town of Seattle, especially as it is ’embodied’ (or ’em-building-bodied’) by Harborview Hospital/Medical Center.
Harborview is the largest hospital provider of charity care in Washington State. It serves as the only Level 1 adult and pediatric trauma and burn center, not only for Washington State, but also for Alaska, Montana, and Idaho, a landmass close to 250,000 square kilometers with a total population of ten million people. In addition, Harborview provides free, professional medical interpreter services in over 80 languages, and has the innovative Community House Calls Program, a nurse-run program providing cultural mediation and advocacy for the area’s growing refugee and immigrant populations.
Here is my photo–simple ode–to Harborview and its adjacent Harbor View Park:
This 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.
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?
There 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.