In Boom or Bust: Standing in Solidarity

Version 2Seattle is a boom or bust town. Boom times: The timber/logging industry of its early days. The jumping off point for people drawn to the Klondike Gold Rush in the Yukon. The Boeing surge during WWII. And, since the 1990s and accelerating over the past four or so years, the technology boom with Microsoft and now Amazon leading the way. The bust times in between, including the Boeing Bust of the early 1970s, spurring the famous billboard near the Sea-Tac airport reading, “Will the last person leaving Seattle turn out the lights.”

Since its early days Seattle has been a socially progressive place. King County, which includes the City of Seattle, was formed by the Oregon Territorial legislature in 1852. From the beginning, the King County Commissioners were responsible for such things as constructing and maintaining public buildings, collecting taxes, and supporting ‘indigents, paupers, ill, insane, and homeless people living in the county.’ Today, while there is a robust safety net in our community, it is not strong enough. Homelessness in the Seattle area is increasing, with tent cities sprouting up wherever they can, including along the original Skid Road (Yesler Way) in the shadows of Harborview Medical Center as shown in this photo taken late last fall.

Homeless encampment near Harborview in downtown Seattle. Photo credit: Josephine Ensign/2014.

As the bumperstickers at the beginning of this post proclaim: Healthcare is a human right; housing is health care. They were produced by the National Health Care for the Homeless Council, of which I am a member. The Council recently issued this timely and hopefully provocative-in-a-good way justice statement entitled Standing in Solidarity: In Support of the Movement for Social Justice. It reads:

“The National Health Care for the Homeless Council recognizes that the significant health disparities associated with homelessness are part of a much larger pattern of injustice in the United States. Poverty and structural racism too often are perpetuated and upheld by poor public policies and narrow social opinion, leaving millions of men, women, children, and youth unable to achieve their potential for well-being and success. We stand in solidarity with the growing social movements and supportive jurisdictions that seek to correct underlying social and economic inequities. We understand that our work as health care providers is part of a much larger struggle to attain human and civil rights, to include the rights to housing and health care.

Numerous recent events involving police violence and community responses have reawakened the national consciousness around the failures of our public systems. Rather than focusing on sensationalized moments and ignoring the daily traumatic violence experienced by those living in poverty, we ask that media outlets instead continue to highlight the root causes of these incidents—social disinvestment, racism, and the ongoing, profound inequities in opportunities, as evidenced by the following:

Public policies created current conditions, but the policy-making process can also promote a robust and inclusive society. We call for measures to establish for everyone in our country the rights to health care, housing, and livable incomes. We also call for those in the Health Care for the Homeless community—and others allied with this cause—to continue our work toward public policies that achieve social justice.”

Falling Off the Funding Cliff of Good Health

cliff-475661_640Words, and especially metaphors, fascinate me. They are powerful and oftentimes unexamined. Take cliff for example. The OED definition of cliff is: “a perpendicular or steep face of rock of considerable height.” Cliffs are both dangerous and exhilarating-seductive. Think of the aptly named Heathcliff (Emily Bronte’s in Wuthering Heights that is, not the rather insipid comic-strip cat). Cliffs represent the edge of the known and comfortable world. Cliffs are good places to gain some perspective.

Cliff, as a metaphor in the health policy world, is used in various ways. First, there is the ‘funding cliff,’ and specifically the current ‘primary care funding cliff,’ also called the ‘community health center funding cliff.’ Community Health Centers across the U.S. are facing a potential federal funding cut of up to %70 this coming fall (for a good and brief article on it, see the Commonwealth Fund’s Washington Health Week in Review, “Health Centers Push for Remedy to Avoid the Funding ‘Cliff,” by John Reichard, 11-3-14). The National Association of Community Health Centers has a policy issues website on the primary care funding cliff with more information and links to policy advocacy that individuals and groups can get involved in. Funding-Cliff-Infographic-1And here is the RCHN Community Health Foundation’s infographic on the primary care funding cliff.











I am a big fan of community health centers (CHCs)  and have worked at three different CHCs in the Seattle area over a period of fifteen years. They typically have very passionate, social-justice oriented people working for them, and they emphasize the use of interdisciplinary teams. CHCs provide comprehensive community-based health care for over 25 million people living in poverty, people who are homeless, as well as immigrant/refugee, and migrant farm workers in urban and rural areas throughout the U.S. CHCs are far from the ‘perfect’ model of care–they are high professional burnout workplaces and they often have much more ‘heart’ than ‘head’ (as in sometimes struggling with good leadership/administration). But they are as close to perfect that I’ve experienced in our country. Not surprising to me is the fact that one of our earliest models of CHCs was the Frontier Nursing Service, started by nurse midwife Mary Breckinridge in 1925 (and still in existence) to provide primary health care in an impoverished rural area of Kentucky.

But to return to the cliff metaphor, a second and important use of ‘cliff’ in the health policy arena is Dr. Camara Jones‘ ‘Cliff Analogy’ framework for levels of health prevention at a population level. Dr. Jones is a family physician and epidemiologist, and currently Research Director on social determinants of health and equity at the Centers for Disease Control. She distills down and illustrates complex health policy/health systems issues through the use of stories and metaphor–the Gardener’s Tale for levels of racism, and the Cliff Analogy for the social determinants of health and of health equity.

In a recent journal article/commentary, Dr. Jones states, “The social determinants of health equity differ from the social determinants of health. While the social determinants of health are the conditions in which people are born, grow, live, work, and age, the social determinants of equity are systems of power. (…) The social determinants of equity govern the distribution of resources and populations through decision-making structures, practices, norms, and values, and too often operate as social determinants of in-equity by differentially distributing resources and populations.” (“Systems of Power, Axes of Inequity” in Medical Care, October 2014, 52(10): S71-S75). In a graphic depiction of these concepts included in her ‘Cliff Analogy,” she shows that the cliff is not a flat, 2-dimensional cliff (as in the infographic above), but is 3-dimensional–differing in how resources, populations, (and, I would add, even the cliff’s physical contours/environment) are distributed.

So on this official President’s Day in the U.S., or Washington’s Birthday for all federal workers, take some time away from the shoe and cars sales and school holiday to consider what actions you can take to make our communities healthier and more equitable places.

Housing is Health Care

House in Richmond, Virginia 2014/Josephine Ensign

Health and Homelessness in Richmond, Virginia in the 1980s: Although I was intimidated by her when I first started working at the Richmond Street Center in 1986, I quickly came to view Sheila Crowley as a valuable mentor.

Sheila Crowley was the Executive Director of the Daily Planet (the lead agency of the Richmond Street Center) from 1984-1992. She left the Daily Planet in 1992 to work on her doctorate in social work, focusing on housing policy. As part of her doctorate, she did a yearlong housing policy fellowship on Capitol Hill. Since 1998 she has been President and CEO of the National Low Income Housing Coalition (NLIHC), based in Washington, DC. The NLIHC works on socially just national housing policy issues, public education, and research. They publish the annual Housing Wage/ Out of Reach Report, which shows side-by-side comparison of wages and rents for all U.S. counties, metropolitan areas, and states.

In my telephone conversation with Sheila several years ago, she characterized the national policy climate as “a disconnect between the response to homelessness and the response to the housing shortage.” She commented on how homelessness has become institutionalized and taken for granted, with so many more people working within the homelessness industry than when it originated in the 1980s, and with even more displacement of low income people from housing.

I had been thinking about similar things. After more than a quarter of a century working with homeless people in the U.S., it disturbs me that there are more, not less people experiencing homelessness, illness, and lack of access to basic health care. There are more specialized services for homeless people in our country than there were three decades ago: homelessness as a problem has become institutionalized. Within the federal government, the Interagency Council on Homelessness includes representatives from fifteen different federal agencies related to homelessness. Homelessness has become an industry. There are currently at least 1 million people working directly with homeless-focused agencies. Homelessness is an assumed aspect of modern American urban life, often portrayed in Hollywood movies as part of a gritty, authentic urban backdrop. I had been asking myself whether by working in the ‘homelessness industry’ I was doing more harm than good: harm in that I helped make homelessness more palatable to people experiencing homelessness, as well as to our housed community members (and yes, even to myself: a literal “I gave at the office” sort of a thing). I haven’t found an answer to my question, but I continue to think it’s an important one to ask.

Sheila gave me broad-brush characterizations of the Clinton, Bush, and Obama administrations’ approaches to housing and homelessness. Under Clinton there was emphasis placed on de-concentration of low-income housing, with the unintended consequence of a net loss of low-income housing units. The Bush administration placed emphasis on increasing home ownership rates, with some funding going to McKinney Homeless Assistance for housing programs. Obama appointed a great Housing and Urban Development (HUD) director, Shaun Donovan, and Sheila had high hopes, but at the time of our interview she felt that not much had been done. The Homelessness Prevention and Rapid Re-housing Program funded through the American Recovery and Reinvestment Act of 2009 appears to have been effective at preventing the worst of recession-related increase in homelessness, although the numbers of unsheltered and doubled-up homeless increased during the 2009-2011 time period.

Sheila and I talked about how even the term ‘homeless’ is problematic on many levels. In the U.S. there have been different official federal definitions for homeless. Until recently the Department of Housing and Urban Development only included the visible or literal homeless—those living on the streets or in emergency shelters. Other federal definitions, such as those necessary for receiving health benefits, have had broader definitions that included people temporarily doubled-up with friends or family, people living episodically in cheap hotels, and people living in cars or other places not intended for human habitation. This definition encompasses people in many different variations of being marginally or precariously housed—as I had been as a young adult. The HUD definition was amended in December 2011 to be more in line with this broader definition of homeless.

Sheila described being at a Homeless Advocates Group (HAG) national meeting recently. HAG is composed of leaders of all the major groups working on homelessness at the national level, including the NLIHC, the National Health Care for the Homeless Council, and the National Alliance to End Homelessness. She looked around the meeting room and realized that all of the leaders of the represented agencies and coalitions were now in their fifties and sixties and had gotten their start in homelessness work in the 1980s. She thought to herself, “Here we go again,” with the increase in the number of homeless, this time due to the national foreclosure crisis and effects of the prolonged recession.

She was quick to highlight success stories, communities that are pulling together coordinated responses to homelessness with a Housing First emphasis—working to maintain people in adequate affordable housing and to quickly re-house people—and a Housing Plus approach of providing supportive housing for people with mental or physical health or substance abuse issues complicating their homelessness. People cannot be healthy unless they have safe and healthy housing. She mentioned Columbus, Ohio and Worcester, Massachusetts as two examples of successful community responses, and added that my new hometown of Seattle has done pretty well with a significant decrease in the chronically homeless population. Across the country, there’s been resistance from emergency shelter providers and church-sponsored programs who see funding and support moving away from their services. But the Housing First movement has had broad bipartisan support since it cuts across different political ideologies.

When I mentioned to Sheila what now stands at the corner of Belvidere and Canal Streets where the Richmond Street Center had been (it is now a VCU college dorm building and a Starbucks), she immediately said, “The only thing I regret about the Street Center building being torn down was the elevator.” This surprised me until I remembered what a practical woman Sheila is—a common character trait of many of the social workers, as well as of public health nurses I have known. She reminded me that the city inspectors had insisted she fund and install a $30,000 elevator in the Street Center building before it could open. She hopes they were at least able to re-use the elevator for another building. She also recounted the construction of the addition on the back of the Street Center for the expanded clinic space I worked in. A sinkhole opened up in the parking lot while they were preparing the foundation. That’s when they discovered that the Street Center was built on land that had been the city dump. Sheila said she went back to where the workmen were standing around looking at the hole, rubbing their chins, exclaiming, “It’s the darndest thing,” and she responded, “Well don’t just stand there, do something about it!”

We need more people like Sheila who don’t just stand around contemplating problems, but who roll up their sleeves and try to solve them.


The Daily Planet

381938823_9c01f8921d_zHealth and Homelessness in Richmond, Virginia in the 1980s: Although I wasn’t sure anyone would come to the clinic at the Richmond Street Center when it first opened (in May 1986), within the first month I had seen fifty different patients for eighty-one clinic visits–meaning patients were returning to the clinic for follow-up visits. After the second month I had seen one hundred nineteen patients for two hundred and fifty visits, and so it grew, all out of the one-room clinic. By the end of the first year of operation, I had seen over sixteen hundred patients for close to four thousand visits. I didn’t need to exaggerate the numbers of people I was seeing. I was treating everyone from newborn babies and their moms, to homeless men in their seventies. The majority of patients were homeless single men in their late twenties who had injuries and skin infections from life on the streets.

Many of the clinic patients were young African-American men from Richmond who had burned bridges with family and ended up on the streets. The crack cocaine epidemic was beginning to reach Richmond from Washington, DC and Baltimore, bringing with it a rising murder rate. Its violence would soon spill over into the Street Center. Some of my patients were not strictly homeless. They were adults with stable chronic mental illness or marginally functional developmental delay, then called mental retardation, who lived in supervised group homes nearby. They moved in and out of homelessness.

The lead agency of the Richmond Street Center was the Daily Planet:  a drug, alcohol, and mental health service agency with its roots in the 1960s counterculture. The Daily Planet social workers got their start by counseling young people coming down off bad trips from street drugs. There were many such young people around the near-by Monroe Park campus of Virginia Commonwealth University. The Daily Planet took its name from Clark Kent’s newspaper of comic book fame; drug-tripping clients (or ‘consumers’ as they called them) said they came out of phone booths after talking with agency staff, and they felt like Superman.

Sheila Crowley, the head of The Daily Planet, repeated this story often, followed by a rumbling laugh. She was tough, staunchly feminist, with long wavy hair and over-sized glasses, long sleeved shirts rolled up over her biceps. Sheila looked uncannily like photos I had seen of a young Gloria Steinem. As if she were a scrappy pit bull with a shredded ear I might see loose on the downtown streets, I gave Sheila a wide berth at first. I could easily differentiate the Planet staff from the consumers; their staff members were all like Sheila. The women staff members were white zealous feminists and the men were Deadhead-type hippies. They were not big fans of any organized religion, but they were tolerant of the varieties of Christian do-gooders they now found themselves working with, for the common cause of combating homelessness.

For the first several years of the Street Center Clinic, I was the only health care provider. We had volunteer physicians who came in on Saturday mornings to see the more medically complex patients. I learned to rely on the social workers, activists, and support staff of the Street Center in order to provide the best care we could. In essence, although this preceded development of the concept, we were trying to address the social determinants of health. I worked at the Street Center for four years before moving on to graduate school in Baltimore. It was not an easy transition and I became homeless myself for six months, so I lost touch with most of the people I had worked with.

Several years ago I was curious what had happened to the various community clinics (and their staff members) I had worked with in Richmond back in the 1980s. I met with Peter Prizzio, Chief Executive Director of the Daily Planet. After Sheila Crowley left, the Daily Planet went through some rough patches with leadership. Peter was brought on board in 2002 and modeled the Planet after Baltimore’s excellent Health Care for the Homeless freestanding clinic. The Daily Planet is now the recipient of the Health Care for the Homeless federal grant I helped write in 1987. The Planet is part of the community mental health safety net, such as it is, for Richmond.

The Daily Planet Clinic is currently located on Grace Street four blocks north of where the Street Center had been. Next door to the clinic is the same pizza place parking lot where I first met Dawn (a young prostituted teen who haunts me still) while doing outreach with the Richmond Street Team. When I returned to the area to meet with Peter, I knew I wouldn’t run into Dawn–she had died of AIDS the year I left Richmond.

Peter is a tall, energetic and engaging man, who gave me a tour of the building, and then we sat and talked for an hour. Peter told me The Planet serves around four thousand patients for thirty thousand visits each year. They have an annual budget of $3.5 million, half of which of which is from the Health Care for the Homeless federal grant. The majority of their patients are long-term Virginia residents, while about 15-20% of the patients are more transient, traveling up and down the I-95 corridor between New York, Baltimore, and Florida. The Planet has primary care providers including doctors and nurse practitioners, dentists, and behavioral health (chemical dependency and mental health) specialists.

Peter told me they are not able to get much support from the City of Richmond. He said that City officials tend to refer to the homeless as “your people,” and view homeless people as shiftless, lazy, and a nuisance to downtown businesses. He described a plan that had been developed a few years back to have a central intake system for homeless and uninsured patients in Richmond. Agencies would pool resources so one case manager could follow patients to ensure their health care wouldn’t be as fragmented. The plan never got off the ground because the agencies were fighting each other for scarce funding for their own programs.



Making America Healthier

Image by Sacred Heart Rehabilitation Center via Flickr

This week I attended the John R. Hogness Symposium on Health Care at the University of Washington. This year’s speaker was Daniel R. Williams, PhD, Professor of Public Health/African and African-American Studies/Sociology at Harvard University. Dr. Williams is a sociologist who studies the social determinants of health, including racial and socio-economic health disparities. He is prominently featured on the excellent PBS series, Unnatural Causes, being interviewed on a variety of topics related to his research.

The title of Dr. William’s talk was, “Making America Healthier: Surprising Steps for Every Health Professional.” While Dr. Williams is an excellent public speaker and delivered a cohesive lecture, most all of the information he covered was the same/similar to what is in Unnatural Causes—so it wasn’t really surprising. I suppose though that it is surprising that the information is surprising to health professionals in the US. He was mostly preaching to the choir here in Seattle. I was also surprised (and bemused) by the pre-lecture conversational content of a group of young students sitting beside me. While looking around at the increasing crowd, one student exclaimed, “Wow! So this is like a big deal!” OK, so we have work to do in our educational system.

Dr. William’s main talking points were as follows: 1) the US ranks near the bottom of all industrialized countries on most all health measures—and we are losing ground; 2) immigrants to the US become less healthy the longer they live in the US (“life in the US is bad for your health”); 3) the racial gap for blacks/whites in health is larger for higher educational levels; and, 4) racial segregation in large US cities in the 2000 census was close to the level of racial segregation in South Africa in 1991 under Apartheid. He stated that health care reform is crucial but insufficient—that we also need to address the social determinants of health in order to make America healthier. He included health behaviors/individual lifestyle choices as something we all need to work on—we are now supposed to eat at least nine servings/day of fruits and vegetables and not just five—while acknowledging how poverty and lack of access to healthy choices makes it more difficult for some to ‘do what’s right’ health-wise.

What can we as health professionals do to make America healthier? Of note is that Dr. Williams is not a health care professional, and that fact was reflected in some of his recommendations. He gave examples of successful programs that incorporate social determinants of health into mainstream health care. Heading his list (yeah!) was the Nurse Family Partnership. Then he talked about the Boston Medical Center’s Medical Legal Partnership, which links low-income families with lawyers—for instance to pressure landlords to remedy asthma-inducing mold and cockroach problems in apartments. The third program he mentioned was Health Leads, started by a Harvard undergrad. This is a service-learning project training college students to staff waiting rooms of safety net clinics, linking patients and families with needed social services.

Dr. Williams ended his talk by giving reference to four resources for further information: 1) Unnatural Causes videos, 2) Robert Wood Johnson’s “Build a Healthier America” report, 3) county-level health data at, and 4) Biology of Disadvantage: Socioeconomic Status and Health (Annals of the NY Academy of Sciences, Feb 2010–free access to report–there is a companion report/also free/less academic, “Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the United States.“)

I was left thinking, “Yes-but?” This all sounds good, but what can individual health care providers such as nurses really do to change things in the health care system? How can we include any of Dr. William’s suggested programs? For instance, our local Odessa Brown Clinic, a safety net clinic in a traditionally African-American Seattle Community, had a grant to include legal services for patients. But once the grant ended, the program ended. Our Washington State Maternity Support Services are on the chopping block in the upcoming legislative session. I suppose we could try to replicate the Health Leads program locally, but with food banks and other basic services being cut, it is hard to know what the students would be linking patients to.

I try to maintain healthy skepticism as opposed to unhealthy cynicism in terms of health policy in general, and the social determinants of health in particular. But Dr. William’s talk left me with the vivid impression of all of us health care progressives spitting into the wind. Even the authors of the Biology of Disadvantage report have somewhat similar sentiments, “…thus we face with humility the task of identifying appropriate poverty-reducing strategies that improve health.” (p.247)