Narrative Medicine Collection

product_thumbnail.phpHere are a few of my current favorite narrative medicine/medical humanities things:

  • Heart Murmurs: What Patients Teach Their Doctors (UC Medical Humanities Press, 2014). This new collection of personal narratives by physicians, edited by my colleague Sharon Dobie, MD, a family medicine doctor who teaches and practices relationship centered care. In these essays Dr. Dobie and thirty-five other physicians explore lessons they’ve learned from patients.
  • Those whacky and wonderful Brits have a much better health care system than we do, and they have this wonderful new (creative) collection (is it a book? is it a collage?) on medical humanities. Published by the Wellcome Collection, Where Does It Hurt? The New World of the Medical Humanities is both entertaining and thought-provoking. (While you’re at it, spend some time browsing their website for fun quizzes, interactive educational games, videos, and more). Here’s what they say abut the book:
    “What does it mean to be well? Or ill? And who, apart from you, really knows which is which? Contemporary definitions of medicine and clinical practice occupy just one small corner of a vast field of beliefs, superstitions, cultures and practices across which human beings have always roamed in the search to keep themselves, and others, feeling well.The label ‘medical humanities’ is the best effort we’ve made so far to define the fence that encloses that very large field; recognising that it’s a space in which artists, poets, historians, film-makers, comedians and cartoonists – in fact every one of us – has as much right to explore as any humanities-schooled or clinically trained professional. This book is a walk through that field, a celebration of its rich diversity, a dip into some of the conversations that are going on within it, an attempt to get it in perspective – and an invitation to you to join the conversation yourself.”
  • The always friendly folks in the middle of cornfields in Iowa (University of Iowa) put on a terrific annual narrative medicine conference: The Examined Life Conference. They just announced that a keynote speaker for their upcoming conference (April 16-18, 2015) is poet Jimmy Santiago Baca. His memoir A Place To Stand (Grove Press, 2002) was made into a documentary released last month.

Ebola: Not In My Backyard

ebola-suit1Until very recently in the United States the general feeling among most people (and among most news reports) was that the catastrophic Ebola epidemic was only a problem ‘over there in the poorest countries of Africa–all of those uneducated Africans who can’t even keep their food from getting contaminated by bat droppings.’ This summer, we were happily dousing ourselves with buckets of ice water in the (dare I say ‘silly and oh so contagious social media’ hype) of the ALS Ice Bucket Challenge. (see my previous blog post: ‘Ice Bucket Challenge for Ebola‘ 8-26-14 for additional perspective on this in light of the global health burden of disease.) At the time that I wrote that blog post we had not yet had any patients tested/confirmed with Ebola in our country. Now, of course, we have multiple confirmed cases in the U.S., including two young nurses who had cared for a patient with Ebola in a Dallas, Texas hospital.

This morning in my community health nursing class of 150 students, I asked how many of them had had any training or preparation or discussion of Ebola in their clinical rotations. Only one student raised her hand and she said that was training through her job at a hospital (presumably Harborview Medical Center in Seattle which supposedly has done a good job of Ebola education and preparedness for its employees). The majority of students said they had been asked by friends or family members for information on Ebola. I encouraged them all to read the excellent training materials for the general public and for health care providers on the CDC website–and to ask for preparedness training in their clinical sites. I also encouraged students to be attuned to subtle and not so subtle racism in news coverage and general conversations about Ebola. Even infographics about Ebola on the CDC website depict only impoverished rural African people with Ebola, in one case showing a man defecating on the ground.

The fact that it is two hospital nurses who are the first confirmed Ebola cases to be contracted in the U.S. should come as no surprise to anyone who knows and loves nurses or who has spent any time in a hospital. Nurses are the front-line, down-and-dirty direct patient care providers. These two nurses were following current (at the time–they have been updated today) Ebola infection control procedures. And whereas the latest nurse with confirmed Ebola, Amber Joy Vinson, was first reported as having breached CDC protocol and flown on a commercial plane while she had a fever, CDC officials are now confirming that she first phoned them when she had a fever and was due to fly: “I don’t think we actually said she could fly, but we didn’t tell her she couldn’t fly,” CDC director Dr. Thomas R. Freiden is quoted as saying. “She called us, (…) I really think this one is on us.” (NYTNew Ebola Case Confirmed, U.S. Vows Vigilance’ by Manny Fernandez and Jack Healy, 10-15-14.)

It is always ironic that it takes ‘big scary disease’ epidemics like Ebola to remind us all of: 1) how connected we are to everyone else in the world–their problems are literally our problem, 2) the importance of sustaining a robust public health infrastructure, and 3) how vital nurses are to our health care system.

 

A Practical Man and Modern Medicine: The Ending

IMG_2700 - Version 2My father died this morning. He died peacefully in his bed at home surrounded by family members, trusted caregivers, and my late mother’s artwork. This photo, which I took a few weeks ago, shows my father ‘getting his daily exercise’ doing laps inside his house using his walker, under the watchful eye of my mother (the painting is her self-portrait about her own heart disease). My father died from the effects of congestive heart failure. When he died, my father wasn’t exactly wearing his boots and gardening gloves, but very close to it. Our family harvested sweet potatoes yesterday from my father’s backyard garden.

Four years ago, when I began this Medical Margins blog, my first post was about my father’s (and our family’s) struggle to negotiate a dignified and peaceful home death for him amidst the Kafkaesque nightmare of our health care system. (See “A Practical Man and Modern Medicine” 9-26-10). I also wrote an essay about my slightly Quixotic efforts to be my father’s cross-country patient advocate and health care proxy through his countless hospitalizations and transfers in and out of nursing homes and home heath care. (See “Home Death” in The Johns Hopkins Public Health Magazine, Special Issue 2013).

During his last hospitalization (a bounce-back hospitalization after only two days at home and before hospice was finally ordered), my father was moved to six different hospital rooms on the same cardiac floor in less than a week. He became more and more distressed and disoriented with each move. He was being treated with three different antibiotics (two IV) for two different hospital-acquired infections. This was despite the fact that my father had clearly documented Advance Directives requesting none of these unnecessary ‘heroic’ measures. It took a direct plea from me to the head of cardiology to have the antibiotics discontinued and my father released to home hospice. That was only three days ago. His (nonprofit, religious-based) home hospice was terrific.

I’ve realized during this final surreal (is ‘Woolfian’ a word? it should be–it has felt very much like her writing in The Waves) month, that we have created a Frankenstein monster: ‘the creature’ or ‘the wretch’ of our health care system (especially the hospital). I’ve realized that my frustration and anger over my father’s end-of-life care is not as simple as displaced grief over losing my father. My anger can not be directed at any one physician or nurse or hospital. Rather, my anger is really dismay (bordering on despair) that I–that all of us– can have been a part of the maintenance of such a sad and broken wretch. Apart from putting all of our hospitals and nursing homes on (the melting) ice flows along with Frankenstein’s monster, what can we do to reform and redeem this creature we have created?

To the Reverend John Edward Ensign, my force-of-nature father: rest in peace.

______________________________

*The Institute of Medicine just released a fascinating study addressing this problem and question: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, 9-17, 2014.

** The NYT recently published a Pulitzer-worthy article by Nina Bernstein: “Fighting to Honor a Father’s Last Wish: To Die at Home” (9-25, 2014).

 

Simple (and Not So Simple) Ways to Help the Homeless

  • IMG_1230 - Version 2Respond with a smile and kind words—even if it is “no—sorry” when you’re asked for a handout for coffee, a meal, or spare change. There’s nothing worse than for a person to be ignored–unless it is for them to be ridiculed, called names, told to ‘just get a job,’ or to become the victim of physical violence. Speak up if you witness someone harassing or demeaning someone who appears to be experiencing homelessness. (See ‘hate crimes and homelessness’ below.)
  • Carry fast food restaurant certificates to give to the homeless when they ask for food.
  • Support and buy Real Change or whatever your local poverty and homelessness newspaper is. Take the time to talk with and get to know the vendor.
  • Support an agency that provides direct services to the homeless, especially agencies that also work on upstream solutions to preventing homelessness, such as low income housing or job training programs. An example of upstream services is Habitat for Humanity whose vision ‘is a world where everyone has a decent place to live.’ Not a shabby vision to have and to support.
  • Become informed and become an advocate for local community solutions to homelessness and poverty, as well as state, national, and international ones. Consider joining advocacy organizations such as the excellent National Low Income Housing Coalition.

Hate Crimes and Homelessness: There is a well-documented relationship between criminalizing homelessness (such as municipal laws against camping or panhandling) and ‘hate crimes’/violence against homeless people. Although homeless status is not currently a protected class under federal hate crime laws, there are local, state, and federal efforts to increase protection of homeless people from being victims of bias and opportunity hate crimes. People experiencing literal homelessness are very visible and vulnerable to being victims of targeted crime.

The National Coalition for the Homeless collects data on violence against homeless people. In their latest report (June 2014), Vulnerable to Hate: A Survey of Hate Crimes Against Homeless People in 2013, they found that documented cases are rising (perhaps partially–but not completely–due to better surveillance and recording efforts. Such crimes remain significantly under-reported.) This is an excellent, balanced, and disturbing report. It includes detailed case studies of victims of targeted violent hate crimes.

Last year there were 109 documented attacks on homeless people, resulting in 18 deaths. There were five documented cases of police brutality of homeless people. Over half of all cases of violence against the homeless were in California and Florida. Nationally, the vast majority of perpetrators were teenage and young adult men. In the report, they call for federal Homeless Hate Crime legislation, better reporting of homeless hate crimes, as well as education/prevention efforts such as education (enlightenment) in high schools and police departments.

Resources to Learn More About Homelessness Issues

Note: This series of blog posts on health and homelessness is based on my unpublished* book manuscript Catching Homelessness. It is the story of my experiences with homelessness, both as a nurse practitioner working with homeless people, and as a homeless person. The stories in Catching Homelessness are about events that have happened to me through my work with homeless people. The stories are all factual in that they actually happened. My perception of them at the time of the events and my memories of them inform the stories. Many of my interactions with people in these stories were within an ongoing professional relationship. Since I recount stories of specific patients I worked with, out of ethical and legal obligations, I have altered some biographical details and changed names in order to protect their identities. I have not changed the names of co-workers and friends except where indicated as such in the text.

I have kept detailed journals, both personal and work-related, throughout my life. These were invaluable resources for writing this book. Because I have a background and training in anthropology, my work-related journals were written as expanded field notes. In my journals I recorded patient stories, direct quotes, profiles and personality quirks of co-workers, my reflections on my actions and on events with which I was involved. I kept copies of my detailed monthly and year-end clinic statistics, narrative reports, and letters that I submitted to the Cross-Over Clinic Board of Directors, for whom I worked; these became sources of information for sections of this book. I also drew upon archived newspaper articles, mainly from The Richmond Times-Dispatch, the leading newspaper in Richmond at the time, and currently the city’s only major newspaper. For some chapters, I relied on interviews with people working with homeless people in Richmond, site visits, and reports (past and present) on homelessness in Richmond, in Virginia, as well as nationally.

The following books and articles were the ones that I referred to the most, or which most influenced my thinking as I wrote Catching Homelessness.

  • Zygmunt Bauman. Wasted Lives: Modernity and Its Outcasts. (Polity Press: Cambridge), 2004.
  • Ted Conover. Rolling Nowhere: Riding the Rails with America’s Hoboes. (Vintage Press: New York), 2001.
  • 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).
  • Kim Hopper. Reckoning With Homelessness. (Cornell University Press: Ithaca), 2003.
  • Joseph B. Ingle Last Rights: 13 Fatal Encounters with the State’s Justice. (Abingdon Press: Nashville). 1990.
  • Jonathan Kozol. Rachel and Her Children: Homeless Families in America. (Three Rivers Press: New York), 1988.
  • Elliot Liebow. Tell Them Who I Am: The Lives of Homeless Women. (Penguin: New York), 1993.
  • Elliot Liebow. Tally’s Corner: A Study of Negro Streetcorner Men. (Rowman and Littlefield Publishers: Lanham, MD), 2003.
  • Paul A. Lombard. Three Generations, No Imbeciles: Eugenics, the Supreme Court, and Buck vs Bell. (JHU Press, Baltimore), 2008.
  • George Orwell. Down and Out in Paris and London. (Harcourt: New York), 1933.
  • Janet Poppendieck. Sweet Charity?: Emergency Food and the End of Entitlement. (Viking: New York), 1998.
  • Christopher Silver, Twentieth-Century Richmond: Planning, Politics, and Race. (The University of Tennessee Press: Knoxville). 1984.

Thanks to the organizations that supported my four years of research and writing of Catching Homelessness: 4Culture, Jack Straw Writers Program, and Squaw Valley Community of Writers. I extend my thanks to the wonderfully supportive librarians in my life, Lisa Oberg and Joanne Rich, of the University of Washington Health Science Library in Seattle. Many thanks to Wendy Call, Waverly Fitzgerald, George Estreich, Drs. Barbara McGrath, Stephen Bezruchka, and Sheila Crowley for reading and providing constructive feedback on earlier drafts. Thanks also to the members of my writing group, The Shipping Group, and to Karen Maeda Allman of the Elliott Bay Book Company in Seattle, for providing writing space and encouragement. A special thanks goes to my husband, Peter Kahn, my son, Jonathan Bowdler, and my daughter, Margaret Kahn, for all their love and support throughout the process of bringing this writing to life.

*Most all of Catching Homelessness has appeared in print in various forms and venues (including in this blog series):

 Some books are meant to be written, but not necessarily to be published. Catching Homelessness is such a book. I’ve moved on to writing my next book, Soul Stories: Health and Healing Through Homelessness. I thank Hedgebrook for the opportunity (starting this next week) for the ‘radical hospitality’ of protected time, space (my own hobbit-house/ ‘Owl’ cottage), food!, and nurturing community of women writers necessary to forge ahead with writing Soul Stories.

 

 

‘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.

_______

Resource:

  • 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

Josephine One copy

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.’