On Strike

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Red Square and Suzzallo Library, University of Washington. Photo credit: Josephine Ensign/2015.

What would happen if you didn’t show up to work, if you walked out of work, if you went on strike? Would anyone notice? Would anyone suffer? Besides earning a (hopefully ‘living wage’) paycheck and (hopefully) decent benefits including heath insurance, how essential is the work we do? And just how expendable are we?

These questions have been on my mind over the past several weeks as a labor dispute rumbles along at the University of Washington in Seattle where I teach. Our faculty members are not unionized, but our teaching assistants are part of the labor union UAW Local 4121. They just voted (90% in favor) to strike if their union representatives can’t negotiate a new work contract with the university by April 30th. Among the union’s terms is one calling on the university to adhere to the City of Seattle’s new minimum wage ordinance that went into effect at the beginning of this month. They are also asking for better health insurance benefits. Their most recent (and first ever) strike was for fifteen days at the end of the academic year in June 2001. Fortunately, I was not teaching at the time, but I understand that the strike created a problem for final exams and grades. (See Columns: University of Washington Alumni Magazine article “Briefing: First Ever TA Strike Hits UW Campus.”)

By now we are all aware of the escalating cost of a college education. An increasing body of research indicates that the largest contributors to this tuition increase are the expansion of the number of university administrators and their inflated (six and seven digit) salaries. The increase in tuition certainly is not going to increased salaries/benefits for most faculty members or to graduate student employees (nor to improved teaching facilities/see paragraph below). An April 5, 2015 NYT op-ed article by Paul F. Campos, “The Real Reason College Tuition Costs So Much,” is refreshingly direct and clear on these issues.

There are approximately 4,500 teaching and research assistant graduate students who work for the University of Washington. My son is one of them, as is my current and best ever teaching assistant. She helps me keep track of and grade all the weekly writing assignments for the close to 150 senior nursing students in a writing-intensive health policy course. She also helps me do battle with the antiquated A-V classroom equipment. Just last week she helped me avoid being electrocuted by a malevolent, malfunctioning microphone that they had jury-rigged to a large boombox on the podium (because the A-V equipment had completely died). I am (still) here to attest to the fact that teaching assistants are indispensable.

And while union membership has been declining in the U.S. over the past several decades, it has been increasing for healthcare workers, and especially for nurses employed by hospitals. That hospitals, including the supposedly not-for-profit hospitals, are big businesses that run like factories, is a well-established fact. Healthcare reform efforts have placed increasing financial pressures on hospital administrators who typically turn these into ‘lean work’ initiatives for the hospital employees below them. ‘Lean work’ probably has some fancy management-speak definition, but it really means that those lower in the food-chain (such as nurses) run their butts off trying to do more work with far less resources.

As Alana Semuels writes in The Atlantic (“The Little Union that Could” November 3, 2014), the small but growing union National Nurses United (NNU) has been especially effective at battling the Goliaths of healthcare power and at winning many of these battles. NNU has pioneered the use of one-day strikes to pressure hospital administrators to provide nurses with the resources they need, such as safe nurse-to-patient ratios and adequate Ebola safety equipment. When Arnold Schwarzenegger was Governor of California and tried to block a state law that would provide safe nurse staffing levels, the nurses of NNU helped to block the Terminator’s block: California remains the only state to mandate safe nurse (RN)-to-patient ratios in hospitals. Yes! Power to the people/nurses!

Here’s some interesting food for thought: When physicians strike, patient mortality goes down; when nurses strike, patient mortality goes up. A physician colleague of mine always tells my students this when he gives a guest lecture in my health policy course. It always grabs students’ attention and it’s not just a random, sensationalized statement. It is backed by a growing number of studies from the U.S. and from other countries (see below). In healthcare, the work of nurses matters. In higher education, the work of graduate student teaching assistants matters.

****** References:

“Evidence of the Effects of Nurses’ Strikes”  by Jonathan Gruber and Samuel A. Kleiner, National Bureau of Economic Research, March 2010.

“Doctors’ Strikes and Mortality: A Review” by Solveig Cunningham, Kristina Mitechell, KM Venkat Narayan, Salim Yusuf. Social Science and Medicine. 2008. 67:1784-1788.

Seattle Times article “Grad students employed by UW vote to strike if contract talks fail” by Katherine Long, April 22, 2015.)

“UW regents flee as student activists speak up” by Katherine Long, April 8, 2015, Seattle Times.

The Travelator of Racism

indexA few blog posts ago I wrote about the use of metaphor in health policy, focusing on the Cliff of Health analogy developed by Dr. Camara Jones. (See “Falling off the Funding Cliff of Good Health”). Dr. Jones is a family physician and epidemiologist who until recently was Research Director on Social Determinants of Health and Equity at the CDC in Atlanta. She resigned from that position in December to become President Elect of the American Public Health Association. She also IMG_3541teaches at the Morehouse School of Medicine. This photograph, which I took on Friday this week, shows Dr. Jones on the right with my colleague and epidemiologist Dr. Wendy Barrington.

Dr. Camara Jones was in Seattle to consult with the University of Washington School of Medicine on diversity issues. She gave a riveting (and standing room only) Grand Rounds talk “Achieving Health Equity: Naming, Measuring, and Addressing Racism and Other Systems of Structured Inequity.” And on Friday she talked with School of Nursing students, faculty, and staff about these same issues. In person she is warm, engaging, funny, and a gifted storyteller. As she says, she uses stories–allegories (which are really extended metaphors with a ‘lesson’)–to distill and clarify complex public health concepts and ‘difficult to discuss’ topics like racism. I highly recommend watching her recent (July 10, 2014) TEDxEmory videotaped talk “Allegories on Race and Racism,” in which she tells four stories: 1) Japanese Lanterns: Colored Perceptions, 2) Dual Reality: A Restaurant Sign, 3) Levels of Racism: A Gardner’s Tale, and 4) Life on a Conveyor Belt: Moving to Action. Conveyor belt, or moving walkway, is also called ‘travelator’ by those clever Brits.

The conveyor belt allegory is one of her most recent, and as far as I can tell she has not yet included it in any of her published articles. Dr. Jones said she has extended the ‘conveyor belt of racism’ analogy from the work of Beverly Daniel Tatum, author of Why are all the Black Kids Sitting Together in the Cafeteria? And Other Conversations About Race, Beverly Tatum (1997). Tatum writes about what it means to be antiracist:

“I sometimes visualize the ongoing cycle of racism as a moving walkway at the airport. Active racist behavior is equivalent to walking fast on the conveyor belt. The person engaged in active racist behavior has identified with the ideology of White supremacy and is moving with it. Passive racist behavior is equivalent to standing still on the walkway. No overt effort is being made, but the conveyor belt moves the bystanders along to the same destination as those who are actively walking. Some of the bystanders may feel the motion of the conveyor belt, see the active racists ahead of them, and choose to turn around, unwilling to go to the same destination as the White supremacists. But unless they are walking actively in the opposite direction at a speed faster than the conveyor belt- unless they are actively antiracist- they will find themselves carried along with the others” (pp 11-12).

It is highly telling that many of the online quotes of this passage from Tatum’s book conveniently delete both sentences that include ‘White supremacist,’ as if  it is ‘that which cannot be spoken.’ Camara Jones extends the conveyor belt/travelator of racism allegory by pointing out there are three stages of anti-racist action: 1) name it–look for and point out the racism inherent in the conveyor belt; 2) ask ‘how is racism operating here?’–not only walk backwards on the conveyor belt, but seek out the mechanisms and the history behind the building of the conveyor belt; and 3) organize and strategize to act with others who are trying to dismantle the mechanism behind the conveyor belt–to stop it. In her Grand Rounds speech, Dr. Jones pointed out that we have to talk about and understand history, we have to ask ‘how did this problem get to be this way?’ “Often knowing and uncovering the history behind how we got this problem can give us ideas of how to address it.”

I continually struggle to find ways to include meaningful course content and discussions about racism and health in the community health nursing and health politics and policy courses I teach, as well as in my narrative medicine/health humanities courses. Using the allegories on racism developed by Dr. Camara Jones has been among the most effective teaching tools.

If you haven’t done this already, try taking the Implicit Association test on race, available online through Harvard University. Make sure you are well-rested and feeling both left-right hand coordinated and willing to have your world rocked before taking this test!

 

A Photo Ode to Harborview

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:

Behold, the shining beacon on the hill,

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Rising from marshland’s King County Poor Farm,

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Stalwart Sisters of Providence did till,

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Shielding paupers, ill and homeless from harm;

Then, to separate church from state, we care,

‘Above the brightness of the sun: Service,’

Proclaimed the poster on opening day;

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Now, our common humanity declare

Responsibility to resurface,

Embrace compassion for all, we say.

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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.

Got Medicaid (Expansion) Virginia?

DSC00367_2My hometown of Richmond, Virginia is fond of putting large statues of white men on horses in the middle of its streets. Richmond is also the setting for a political and health care drama of Southern Gothic proportions. Virginia is an ACA non-Medicaid expansion state, but the state’s leaders have been debating Medicaid expansion over the past year. Earlier this month Phillip P. Puckett, a Virginia Democratic state senator, suddenly resigned to take a job on the Virginia tobacco commission. Curious circumstances surrounding his resignation have led to an investigation by the U.S. Department of Justice and the FBI, as reported in this recent Richmond Times Dispatch article. His resignation flipped control of the Virginia State Senate to Republicans intent on blocking Medicaid expansion efforts. Today Virginia Governor Terry McAuliffe announced his plan to bypass the recalcitrant Republican General Assembly and expand Medicaid to 400,000 low-income Virginia residents. (see: Modern Healthcare Va. Governor to Bypass Lawmakers, Expand Medicaid, 6-20-14). Governor McAuliffe also plans to block funding a $300 million facelift of the Capitol complex where many of the lawmakers have their offices. The bright and shiny Virginia State Capitol is shown in this photo I took about a year ago.

Medicaid plays vital roles in people’s lives and in our health care system. Medicaid improves access to basic health care services for millions of our children, low-income adults, the elderly (long-term care services), and people with disabilities. Medicaid saves lives. Medicaid funds large portions of our public hospitals, health centers, and nursing homes. Without Medicaid, most of our children’s hospitals would be forced to close.

Several of my struggling small business owner nieces and nephews who live in Virginia would benefit from Virginia’s Medicaid expansion. My elderly father who lives in Richmond would benefit from Medicaid expansion for long-term care services not covered by Medicare. My own son who lives in our Medicaid expansion state of Washington is about to get Apple Health, our version of Medicaid because the University of Washington has ended their student health insurance plan–or at least what was masquerading as a health insurance plan (see my previous post, “My Young Invincible, His Lost and Found Toe, and University Health Insurance that ‘Technically Isn’t'” 4-23-14).

Virginia and other Southern states have high ratios of physicians to the general population, yet have the worst poverty and shortest life spans of any region in the U.S. Virginia has the second highest number of free clinics in the country. North Carolina has the most and Georgia is close to Virginia’s number. Most of the free clinics are faith-based and pride themselves on not accepting any ‘government handouts.’ This generally includes the clinics not accepting Medicaid or Medicare reimbursements. These Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free health clinics part of the solution or part of the problem?

The deeply entrenched American notion of charity care as the way to provide safety net services engenders stigma, shame, dependency, and resentment among recipients. Charity care is especially pronounced in the Bible Belt South. People do not want to have to depend on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society—sorts us into the haves and the have nots, into worthy and unworthy citizens. Charity care perpetuates poverty. Despite compassionate staff and health care providers, charity care is always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive. I know this first-hand, having been on both the giving and receiving ends of charity health care.

Medicaid and Medicare are both basic entitlements; they are not charity care. So Virginians, come down off your high horses and get Medicaid expansion.

The Intima: A Journal of Narrative Medicine

Devilsih Dealings in Hospital Mergers

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devilish latte (Photo credit: strikeseason)

Hospital mergers between faith-based (mainly Catholic) and secular healthcare systems are picking up speed and setting off more alarm bells across the country. Here in my home state of Washington–one of our nation’s most secular and socially progressive states–we are quickly becoming the state with the largest percentage of Catholic hospitals. If all of the pending hospital mergers go through, more than half of all hospital beds in Washington State will be in Catholic hospitals. How can this be?

In my previous blog post “God and Mary and Jesus are back….and Coming to a Hospital Near You” (February 27, 2012) I wrote about the concerns raised by the merger of Seattle-based secular Swedish Hospital with Seattle-based (Catholic) Providence Health and Services. As part of the merger deal Swedish Hospital dropped its abortion services. Since the merger, employees have reported they are not allowed to talk with or refer patients for pregnancy termination or give patients resources about our state’s Death with Dignity Act. There are also concerns voiced about the merger’s effect on access to and quality of health care for LGBTQ individuals.

My own physician is part of Swedish and I’ve had conversations with her about whether or not my end-of-life wishes/Advance Directives would be honored if I ended up in a Providence/Swedish hospital. I considered switching health care providers, but now most all in the Seattle area are affiliated with Catholic hospital systems. Even the University of Washington Medical Center is merging/affiliating with PeaceHealth, a large Catholic healthcare system. You have to wonder about these names. Who can argue (especially all of us Pacific Northwest hippies) with a name like PeaceHealth?

As I stated in my previous post– I am all for religious freedom. But I also believe that the separation of church and state goes both ways—not only protecting the
church/religion from the bully-power of the state, but also the state
(government and civil society) from the bully-power of the church.

The ACLU of Washington has taken up the issue of hospital mergers and hosted an excellent panel discussion last week on this topic at Town Hall, Seattle. You can hear a full recording of it here. The audience Q&A session was the most interesting part of it for me. Someone asked why no hospital administrators were on the panel. The answer from the organizers was that they wanted an educational forum and not a public debate–and that hospital administrators had ample resources and platforms already for voicing ‘their side’ of the issue. A woman asked what the ramifications will be for health science student education at University of Washington with the merger/affiliation with PeaceHealth. Two of the panelists were UW faculty members and one replied, laughingly, that they weren’t authorized to answer that question. How sad and how telling and oh how political health care is in our country.