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.

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…

Framing Homelessness

Rough sleeping in the U-District. Photo credit: Josephine Ensign/2016

Homelessness is in the news almost every day here in my hometown of Seattle. Unless you happen to live in a gated community and never go outside your protected home, there is scarcely a city block you walk without distinct signs of people living rough outside or in cars or RVs. It is no surprise then that our One Night Count of homelessness by the Seattle/King County Coalition on Homelessness last week found 4,505 people homeless/without shelter, a 19% increase from the One Night Count in January 2015. And this is despite the fact that the One Night Count volunteers (including a group of our UW Seattle nursing students) being unable to enter and count homeless people in ‘The Jungle,’ a longtime homeless encampment area in an I-5 greenbelt area of Seattle–and the location of our impressive Depression Era Hooverville. There had been a mass shooting in The Jungle the night before, resulting in the death of two homeless people and the hospitalization of three others.

Just two months ago, in November 2015, Seattle Mayor Ed Murray declared a state of emergency over homelessness, saying this in the official notice: “The City of Seattle, like many other cities across the country, is facing a homelessness crisis. The region’s current needs outweigh shelter capacity, leaving too many seniors, families and individuals sleeping on the street. More than 45 individuals have died while homeless on Seattle streets in 2015 alone.” His declaration of a state of emergency supposedly helps “deploy critical resources more quickly to those in need.”

Suddenly it begins to feel like we’ve entered a 1980s time-warp, with so many people weighing in with competing viewpoints, priorities, and proposed ‘fixes’ for our homelessness problem. I, of course, could add my own voice to the rising cacophony surrounding this latest round of the homelessness crisis. Instead, I offer these words of wisdom and perspective from some of my favorite deep and critical thinkers on the topic of the ‘first wave’ of modern homelessness in the 1980s:

  • “The scandal of homelessness looked as though it could harness a new politics of compassion and shame–compassion for the plight of the dispossessed and shame at the inhumanity of national and local policies toward them. Homelessness, in sum, had political appeal.” pp 132-133, in Donald Schon and Martin Rein’s excellent book, Frame Reflection: Toward the Resolution of Intractable Policy Controversies. Basic Books, 1994.
  • Put plainly, the opposite of homelessness is not shelter, but home. Understood culturally, ‘home’ must entail some claim to inclusion. The principled question underlying homelessness policy, then, is not, what does charity demand? but rather, what does solidarity require? And so it no longer suffices (if it ever did) to ask what it is about the homeless poor that accounts for their dispossession. One must also ask what it is about ‘the rest of us’ that has learned to ignore, then tolerate, only to grow weary of, and now seeks to banish from sight the ugly evidence of a social order gone badly awry.” p. 214 of Kim Hopper’s now classic book, Reckoning With Homelessness. Cornell UP, 2003.

‘Send these, the homeless, tempest-tossed to me…’

statue-of-liberty-267948_640Health and Homelessness in Richmond, Virginia in the 1980s: What causes homelessness? Homelessness is often portrayed as an illness, caused either by individual flaws, such as substance abuse or mental illness, or by societal flaws including the lack of affordable housing, the weakness of our welfare system, and the deinstitutionalization of the chronically mentally ill. Advocates for the homeless generally emphasize societal flaws, while government agency personnel emphasize individual flaws. Our country is founded on the “pull yourself up by your bootstrap” mentality, so we all inherently want to believe that people are lazy or somehow defective if they are homeless and haven’t “made it” in life. Perhaps our Puritan roots are responsible for the common moral judgment placed on homeless people—and the judgment that homeless people often place on themselves.

Feeding off other deeply held American values of courage, adventure and the frontier spirit, homelessness, especially in young people, can be romanticized in Mark Twain’s Huck Finn sort of way:

“I reckon I got to light out for the Territory ahead of the rest, because Aunt Sally she’s going to adopt me and sivilize me, and I can’t stand it. I been there before.”

This version of homelessness is tolerated and even socially sanctioned for young men in search of themselves—less so for young women. It is, of course, more dangerous for young women.

Throughout recorded history there have been different groups of people who would now be called homeless: wandering minstrels, vagrants, skid-road (or skid row) bums, people riding the rails/hobos, and even people on religious quests like the Christian Crusaders. The homeless, referring in this case to immigrants, or more starkly “the wretched refuse of your teeming shores,” is included in Emma Lazarus’ sonnet inscribed on the Statue of Liberty: “Send these, the homeless, tempest-tossed to me/I lift my lamp beside the golden door.” In one sense, all of us, except perhaps indigenous Americans, originate from homeless stock.

One of the main social service agencies at the Richmond Street Center was Freedom House (the agency closed in May 2013 after thirty years of service). Freedom House was modeled after Dorothy Day’s Catholic Worker “houses of hospitality,” and run by Larry Pagnoni, an energetic Catholic guy, with the aura of a priest in jeans. He was twenty-four years old when the Street Center opened, and he had spent a week or so living on the streets to find out what it was like.

The Freedom House staff members were all mostly young, college educated, and from middle-class families. They lived in voluntary poverty in run-down housing in Jackson Ward near the Street Center. In a way, they embraced poverty and homelessness (or at least being marginally housed). They got their clothing from the church clothing closets and their food from the food banks. None of them seemed to have medical insurance, so they relied on charity medical care, including what I provided at Cross-Over Clinic. At the time, that didn’t seem odd to me. Sometimes I couldn’t tell who was a Freedom House staff person and who was a homeless client. I think Larry liked it that way. The Freedom House philosophy was similar to Liberation Theology, with God loving the poor and the homeless preferentially, and with Christians called to fight for social justice by whatever means necessary, short of actual physical fighting.

In talks Larry gave to church groups or to the local media, he liked to pull out a key that he always carried with him. He said the key was to his parent’s house and he pointed out that most people who aren’t homeless have a literal or figurative key to a family member’s house or apartment; they have the necessary family connections as a fallback when times get tough, connections so they won’t end up homeless. He used the analogy of having a family member who was struggling more than others. Maybe they had a mental or physical health problem, substance abuse—a person who could become homeless without their family support system, without people lending a hand or offering a place to stay. Larry said that what caused homelessness was a combination of individual vulnerabilities and failures of the various support systems—family, health care, housing, job training.

During my years working at the Richmond Street Center, I struggled with the issue of the worthy and unworthy poor, the worthy and unworthy homeless. It was an idea that was debated in the local news (although they used more polite terms); it was an idea that had been debated throughout history. There were always people who were more vulnerable through no fault of their own, and there were always people who took advantage of assistance. At that time, the majority of Richmonders prided themselves on their Southern hospitality and Christian charity. Most Richmonders had not yet burned out on helping the homeless.

From my visits back (including a week ago) to Richmond to visit family members, from my site visits and interviews with people working in direct services for Richmond’s homeless population, as well as from observations as I walked the area where the Street Center had been, it appears that many Richmonders are a bit crispy/burned out on helping the homeless in truly meaningful, systemic ways. I do recognize that my experience (all of it, including spiraling into homeless in Richmond, including my ‘geographical cure’ of moving first to Baltimore and then to Seattle) has given me a different lens through which to view these issues.



  • Kim Hopper. “Homelessness Old and New: The Matter of Definition.” In, Understanding Homelessness: new Policy and Research Perspectives, Dennis P. Culhane and Steven P. Hornburg eds., (Fannie Mae Foundation, 1997).

Still Homeless

DSC00331 - Version 3Health and Homelessness in Richmond, Virginia in the 1980s: Twenty-five years after leaving Richmond, I returned to the corner of Belvidere and Canal Streets where the Richmond Street Center had been. I searched for remains of my past work with Richmond’s outcasts, for my own past as a homeless outcast.

Standing on the street corner in Richmond, I noticed that the empty lot adjacent to the Street Center, the lot that had been a curtain of kudzu vines, trees and trash when I worked there, was gone. Traffic whizzed by. Belvidere remains a four-lane street, a major north south arterial through Richmond, with heavy car, and truck traffic. As I stood on the corner, staring at the specter of what had been the Street Center, it morphed into an emerald green mermaid: a large Starbucks stands there now. For all its stamped sameness, Starbucks signals comfort and home to me, since I found refuge in its watery birthplace of Seattle. The Starbucks is on the ground floor of a fancy brick three-story VCU student college residence hall where the Street Center had been.

Looking at the Starbucks, I had a vision of Bruce,* a former patient of mine who I’d always had a soft spot for. One of the River Rats, Bruce was white-haired, shrunken, and fond of wearing overalls. I’d often see him on the sidewalks near the Street Center, pushing a metal shopping cart full of aluminum cans and a large black plastic garbage bag, with a little white dog perched on top of the pile, wagging her tail. Bruce was a boisterous alcoholic, so usually the cart didn’t go in a straight line. He liked to give away presents he kept buried inside the garbage bag: packs of Marlboro cigarettes smuggled out of the Philip Morris plant by a friend of his who worked there, and packages of Twinkies and bright pink Sno Balls from the nearby Hostess factory. With his scraggly grey beard and the bag of presents, he was like a back-alley Santa. Bruce’s dream was to get a trailer of his own where he could be left alone to drink until he died.

Bruce had been one of the nicest of my regular patients at the clinic. Even when he got drunk he wasn’t mean: if anything, he got kinder and gentler. He didn’t have a chip on his shoulder, didn’t project an “I’m angry at the world for being given such a bum rap in life” attitude. Some of the clinic regulars at the Street Center were so weighed down by anger they staggered beneath it. Bruce shuffled. He was plain sweet.

As I stood on the street corner, looking at the Starbucks store and remembering Bruce, I became aware of a figure darting between cars, crossing the street toward me. It was Bruce, minus the overalls, garbage bag full of Twinkies, grocery cart, or his little white dog. But it was Bruce, still with the same happy demeanor and not looking twenty-five years older. I had been writing about him that morning, convinced he was dead, hoping he had gotten the trailer to live in before he died.

“Nurse Jo!” he yelled as he hopped up on the sidewalk beside me, grinning. On the street corner near us was a middle-aged white man holding a cardboard sign, with large hand-written words: “Homeless Veteran. Anything Helps.” I hadn’t noticed him before. He turned toward us. I saw it was James,* another former Street Center clinic patient of mine. He and Bruce were longtime friends, both were Viet Nam vets, and both were River Rats.

I talked with them for a while, imagining this was all part of a bad Southern Gothic version of a Woody Allen movie script. Bruce told me he had tried to drink himself to death but it hadn’t worked. The VA doctors were good and they were taking better care of him than they used to. He had a room in a house in Oregon Hill and had managed to stay there most of the time over the past ten years. He never got the trailer home he’d wished for. He’d cut back on his drinking and his blood pressure was better. The two men gleefully compared blood pressure readings, trying to impress me. Nurses are supposed to like that sort of thing. James had been living in Florida for a while and had just hitchhiked back to Richmond the day before. He was camping down by the river with buddies, with other modern-day River Rats.

“Mad Dog died last month, man. Did you hear Mad Dog died?” Bruce asked James. I didn’t know Mad Dog. While they were making plans to hook up later, I looked past them to the south. I could see cars speeding past us on the Downtown Expressway. Under the Belvidere Street Bridge that crosses the Expressway, I saw a group of four white young adults sleeping on old mattresses. At the top of the hillside above them there was a large hole in the fence, and beyond that was a boarded up house on the edge of what remained of Oregon Hill. The Hollywood Cemetery and Confederate shrines remain. Nothing had changed and everything had changed.


Take a look at the great (short) documentary video about a Seattle-based play Don Quixote and Sancho Panza: Homeless in Seattle, written by Rose Cano, a  Spanish medical interpreter at Harborview Medical Center Emergency Department. The play is in response to a question she asked herself, “How do people maintain their dignity while being homeless?” As she explains in this video, one of her answers is: through the friendships and ‘street family’ relationships that develop for many people—including for people like Bruce.

* Names and other identifying details of former patients have been changed.

Cross-over Clinic: Church and State

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Cross-Over Clinic/The Richmond Street Center May 1986/Josephine Ensign

Health and Homelessness in Richmond, Virginia in the 1980s: The clinic I worked for at the Richmond Street CenterCross-Over Clinic*—was started by physician Cullen Rivers and his Presbyterian church friend, the Reverend Judson “Buddy” Childress. Buddy had been a life insurance salesman before going to seminary.  His ministry was to business and professional people, as he said: “linking the talents and resources of suburban Richmond to the needs of the inner city poor.” For two years before the Street Center clinic opened, Cullen and Buddy had run a Saturday health clinic out of a downtown Richmond storefront apostolic church.

Balding, with long sideburns as bookends around a serious, intelligent-looking face, Cullen was prone to wearing cardigans. He was practical and caring in a genuine way, one of those people with a quiet personal faith you wouldn’t mind having yourself, even if you were agnostic. Some people have a loud, yelling at you through a megaphone, obnoxious sort of faith. He wasn’t like that, and it was one of the things that attracted me to Cross-Over Clinic. That, and the fact that he and Buddy were trying to provide free basic health care for poor people. Cullen was my main medical back-up, available to me by phone for questions; he exuded an unflappable, competent demeanor, as well as respect for me as a nurse. Buddy convinced the local Sisters of Bon Secours to pay my salary. I was the first employee of Cross-Over Clinic and began my work at the Street Center in May 1986 (photo is of me on the first day of clinic).

Over the nearly four years that I worked at Cross-Over Clinic, I grew as a health care provider and as a person. I was the sole health care provider M-F at the clinic for the first three years, before a Health Care for the Homeless grant (with the Daily Planet as lead agency) allowed Cross-Over Clinic to hire Dan Januzzi as a full-time physician. Cullen and other volunteer physicians and dentists came in on Saturdays to provide care for the more complicated patients.

Nurse-run clinics were rather frowned upon in Virginia (and still are), and less than six months into beginning my work, the Virginia Health Regulatory Board opened an investigation of my ‘too independent’ practice. I’ve written about this experience in a previous blog post, “Not Just Culture” (11-19-11). And, as I’ve written before [see my recent “No Place Like Home(less)” in Pulse: Voices from the Heart of Medicine], even though I was never charged with anything, the stress of the 18-month long investigation into my practice contributed to the loss of my faith, job, family, and home: I spiraled into homelessness.

It didn’t help that when Buddy became the clinic director during my final months there, he admonished me not to refer women for abortions and to council patients with HIV to repent of their sins. When I refused, he put me on a mandatory leave-of-absence to be spent in ‘prayer and reflection to ask for a humble and teachable spirit.’ He also admonished me to return to church and to my husband from whom I was separated. The Cross-Over Clinic lost the Health Care for the Homeless grant funding due to issues of–shall we say–lack of appropriate separation of church and state. The Cross-Over Board also decided to focus its mission on the ‘working poor’ rather than on the homeless population. I did not part from Cross-Over Clinic on the best of terms.

Several years ago I decided to revisit Cross-Over Clinic to see what they’re up to and perhaps to try and heal old wounds. I was scheduled for an interview and site visit with Dan Januzzi, still the Medical Director of the clinic. Dan and I hadn’t parted well, but he was friendly and welcoming on the phone when I talked with him to schedule a visit. He is committed to what he calls poverty medicine, charity care medical practice focused on indigent patients.

I drove down Belvidere Street, past the corner where the Street Center had been, and across the James River. In amongst rundown Pentecostal churches, greasy car repair shops, and towing companies, sits Cross-Over Clinic. The building looks like it might have been a used-car dealership. Printed signs greet you when you enter: “We are sorry if you have to wait to see us. Thank you for your patience,” and, “Cross Over does not receive direct government funding. Our services are possible through funding by the community.”

The waiting room was small and cramped, with fifteen or so patients already seated. I checked in at the front desk and was told to have a seat. At first I was irritated, then amused, sitting there in the waiting room of a clinic where I had once worked–in a clinic that had changed my life so profoundly. A woman seated next to me started cussing loudly at no one in particular about the long wait times. After an hour of waiting I decided I had experienced enough; I left and have not returned.

From public records, I discovered that Cross-Over Clinic has an annual budget of $2.5 million, and receives an additional $2 million of in-kind donations: doctors, nurses, dentists and pharmacists volunteer for Saturday clinics—they call these “mission trips that you don’t have to leave the country for.” A local private hospital does $800,000 of clinic lab work per year free of charge and the hospital uses it as a tax write-off. VCU/MCV Medical Center (one of my alma maters) sends nursing, pharmacy, and medical students to assist with clinic. Cross-Over sees about the same number of patients per year as the Daily Planet clinic, although they include outreach screenings in churches by lay volunteers in their patient numbers.

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 free clinics, like Cross-Over, are faith-based, and since George W. Bush’s Faith-Based Initiative, are legally able to discriminate in provision of services and in hiring (and firing) practices. George W. extended his father’s campaign to blur the separation of church and state.

I find it ironic that the principle of the separation of church and state had its founding in the U.S. in 1786 less than a mile from the Richmond Street Center, at the Virginia General Assembly, when they voted in favor of Thomas Jefferson’s Virginia Statute for Religious Freedom. This statute was the forerunner of our country’s first amendment protections in religious freedom. Part of Jefferson’s statute stipulated that no person could be compelled to attend any church or to support it with taxation.

President Obama promised to reverse the erosion of basic civil rights (and the erosion of separation of church and state) from the Faith-Based Initiative, but so far, he has not done so. U.S. Congressman Bobby Scott from the 3rd District in Virginia, which includes Richmond, is trying to address this issue. He is the first African-American congressman from Virginia since Reconstruction, and he has an excellent ‘Faith-Based Initiative’ information page along with an explanation of how it allows discrimination based on race, gender (and, I would add–sexual orientation), as well as on religion.

While I don’t agree with how I was treated as an employee of Cross-Over Clinic, and neither do I agree with their principles of ‘poverty medicine,’ I know that many Richmonders view Cross-Over clinic as an essential part of their health care safety net. Which is probably true given the fact that Virginia has an extremely ‘hol(e)y’ health care safety net [see previous post: “Got Medicaid (Expansion) Virginia?” from 6-20-14).

* The clinic was called/spelled ‘Cross-Over Clinic’ when I worked for them. Since then, they have variously called themselves ‘Cross Over Clinic’ and ‘CrossOver Clinic.’

Virginia Relics Part Two: Eugenics

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Skeleton in the Library 2014/Josephine Ensign

Health and Homelessness in Richmond, Virginia in the 1980s: A companion to Virginia’s Racial Integrity law (see previous blog post ‘Virginia Relics Part One: Racism’), The Eugenical Sterilization Act, was also passed into Virginia law in 1924. This was part of Social Darwinism, The Progressive Movement and eugenics: bettering society through social and scientific engineering. Margaret Sanger, the nurse and founder of Planned Parenthood, was part of this movement. The pseudo-science of phrenology–measuring the skull to predict IQ and criminality–was part of eugenics.

Virginia’s Sterilization Act mandated involuntary sterilization of people institutionalized with mental retardation,*  severe mental illness, and epilepsy. It also applied to prison inmates. They were all the defectives or delinquents, viewed as a drain on society–they should be eliminated. People who were institutionalized and considered feeble-minded included the shiftless poor, homeless, runaway teens, chronic inebriates, and oversexed women. Physicians could involuntarily sterilize women of normal intelligence who were deemed promiscuous. Promiscuity was defined as having a baby outside of marriage, having multiple sexual partners, being a white woman with a black partner, or working in prostitution.

When Virginia passed the Sterilization Act, eugenicist physicians looked for a suitable test case to seal it into law. The physician in charge of the Virginia State Colony for Epileptics and Feebleminded found his ideal candidates in three generations of Buck women. The elder and widowed Mrs. Buck had been confined to the Colony for having illegitimate children. One of her daughters, Carrie, had gotten pregnant at age sixteen—the result of rape by a young man in her foster family. A Red Cross nurse declared Carrie’s daughter, Vivian, feebleminded at six months of age. The nurse reported in official expert testimony that Vivian was “peculiar,” with “a look about it that’s not quite normal.” The head of the Virginia Colony wanted to sterilize all three of the Buck women. The case went to the U.S. Supreme Court, where Chief Justice Oliver Wendell Holmes, Jr. likened involuntary sterilization of degenerate offspring to state sanctioned immunizations. The Supreme Court Justices ruled in favor of Virginia, so the Buck women were sterilized—except for Vivian who died at age eight in the care of the same foster family where her mother had been raped.

After the Supreme Court ruling, Virginia physicians aggressively pursued the Sterilization Act, giving Virginia the highest per capita rate of involuntary sterilization of the “feeble-minded” and other undesirables. One of the main Virginia eugenics physicians, Dr. Albert Priddy, wrote to physicians in Nazi Germany praising their work and bemoaning the fact that the U.S. lagged behind the Nazis in the eugenics movement. During the Nuremburg Trials after World War II, defense attorneys for Nazi doctors cited the Buck vs. Bell U.S. Supreme Court ruling as justification for the Nazi doctors’ involuntary sterilization of hundreds of thousands of people. Buck vs. Bell has never been overruled. Virginia’s Eugenical Sterilization Act wasn’t repealed until 1979, just a few years before I started nursing school.

Before my work at the Richmond Street Center, I was vaguely familiar with these parts of Virginia history—of how my home state tried to not only designate and separate the desirables from the undesirables, but also to extinguish the undesirables. Some of the activist social workers at the Daily Planet talked about it. But it was embarrassing, something I preferred not to think about. I was able to avoid thinking about these laws because I viewed them as relics from a past that didn’t affect me. My work at the Street Center–and especially with a patient named Sally**– changed that. Sallie lived with her alcoholic mother in the heart of the all-white and impoverished Oregon Hill, located across Belvidere Street from the Street Center. Sally had an IQ of 45. One day several years into my work at the Street Center, Sally came into our clinic complaining of belly pain. I discovered she was four months pregnant. She was obese and wore baggy clothes, so no one had noticed her expanding belly.

Within the first year of opening, the Street Center had become a popular hangout for Richmond’s marginally housed adults, including many who had mental retardation and mental illness. They moved around to live with different relatives, or they lived in cheap, moldering old downtown hotels. Others lived in Richmond’s numerous group homes. Many of these homes were located less than a mile from the Street Center, a straight shot north up Belvidere Street where it turned into Chamberlayne Avenue. Chamberlayne had huge, stately old brick homes, now abandoned in the White Flight after school desegregation. The houses had been converted into group homes, domestic abuse shelters, a teen runaway shelter, and even an animal shelter. It was a social service ghetto.

Group homes had opened in response to deinstitutionalization efforts in the 1970s and early 1980s, as mentally retarded and chronically mentally ill people were moved out of state-run long term care institutions and back into the community. The idea was a good one: provide supportive home-like living situations and community mental health care. But no one wanted group homes in their neighborhoods, so the homes ended up clustered in low-income areas. Most of the group homes in Richmond were poorly run, inadequately staffed, and lacked licensing oversight. There was also a deficit of community-based mental health and support services for the residents of group homes.

The Street Center social workers tried to be alert for clients like Sally with mental retardation or chronic mental illness and to tie them in with alternative services. These clients were vulnerable to being preyed upon by the street-hardened homeless men in the center. The Street Center had free meals, lax rules, and staff members who were earnest, kind-hearted young people. The building was always bustling with activity, so it was a magnet for people like Sallie.

By the time I discovered her pregnancy, Sally was past the window for being able to have an abortion–even if her deeply religious mother had agreed to one. As a nurse I was required by the state to report suspected child abuse and neglect, which this seemed headed toward. I didn’t like being part of a system that could take children from their parents. I didn’t like being an agent of social control, but I knew I had a duty to protect vulnerable children.

A simultaneous and distasteful part of my job was dealing with the childless, infertile white upper middle class Christian married women who hovered around our clinic in search of suitable babies to adopt. I was a mother by then, so I understood some of what it must feel like to desperately want a baby and not be able to have one. But the childless women would drop off bizarre advertising materials: pages of contact information, written statements, and formal studio photos of them beside their husbands. It felt obscene that they were shopping for babies at the Street Center and taking advantage of an already marginalized population. Since our clinic was run by a conservative Evangelical Christian organization, I allowed the women to leave their advertisements. What the women didn’t say directly but carefully implied was that they only wanted white babies. And they certainly didn’t want to adopt a baby from a white mentally retarded woman like Sally.

* Terms such as “mentally retarded” or “developmentally disabled” I use based on accepted terminology within the U.S. medical and legal realms of the particular time period I am writing about.

** Names and identifying details have been changed, and in this case I have chosen to use a composite patient.





Virginia Relics Part One: Racism

Virginia State Capitol, Richmond 2014/Josephine Ensign

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

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

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

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

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

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

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

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

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


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.



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.