Selfie-Healthy Health Care

IMG_1897 - Version 2What does Obamacare/ACA mean to me in terms of my personal health care now that the 2014 roll-out is officially in place?

I have the same job-based health insurance through the same health insurance company that I’ve had for the past two decades. I’m sure that they have continued to raise my deductibles and co-pays this year as they have in most years, but, truthfully, I have ceased to pay much attention to those details.

The biggest change that certainly has gotten my attention was a recent mailing I received with the following highlighted in bright orange: “Premium surcharges and a wellness incentive are coming! Take action on the four steps below.” I knew these were coming and had already taken their wellness survey back in December just for grins (see blog post My New Year’s Resolution: Avoid Wellness Programs, 12-30-13). As the blog post title implies, I had planned to ignore this Big Brother naughty or nice-style intrusion on my sense of privacy, but then I read the next highlighted item on the mailing: “What happens if I don’t respond…?” Answer: I’d start being charged a $25 per month tobacco use surcharge (even though I am a never smoker) and I’d forfeit a $125 reduction on my 2015 medical deductible. Opting out this year would cost me $425. The ACA/Obamacare allows employers to offer larger health/wellness incentives, up to 30% of the cost of coverage, so my health insurance company could hike up these ‘incentives’ (penalties?) considerably in the future.

Begrudgingly, I signed onto their website to attest to not using tobacco products. Then I chose a primary care provider (who I haven’t seen in two years because she is too popular/busy/on her way to becoming another burnout statistic). Then I had to re-take their silly, non-evidence based health assessment. It still tells me I need to stop eating a high-fat diet when I’m a vegetarian. Finally, I registered for one of their wellness program activities: doing at least 90 minutes of moderate to vigorous physical activity per week for at least 10 consecutive weeks. Walking, swimming, cycling, yelling profanities at my health insurance company and our health care system…..Great. OK. Go away you silly premium surcharge/personal wellness incentive that raised my blood pressure!

Just when I thought I was done with all of that for the year, I got an e-mail invitation from my insurance company inviting me to enter a HealthieSelfie photo contest on their Facebook page. All I have to do is ‘snap a selfie’ of my wellness goals and send it to them, to what? share with all their other selfie health care absorbed health plan enrollees? The ultimate of (flat, fit, no flab allowed) navel-gazing healthism? An example of medical sociologist Deborah Lupton’s imperative of health? A fun, harmless, effective way to use social media to promote personal health (and thereby enable the health insurance company to reap more health plan profits)? Yes to all of the above.

Having never taken a selfie before, my first attempt resulted in a photo of my thumb. I find deep symbolism in that. The photo here is my second attempt, and shows me ‘doing’ my 2014 selfie-wellness goal: Less time trying to figure out our crazy health care system and more time in my garden playing with my Corgi.

What Do You Think of Obamacare?

DSC01678Besides having a severe case of jet-lag and change-of-hemisphere-lag upon returning to Seattle from New Zealand, one of the more disorienting re-entry issues I’ve encountered this week has to do with our health care system.

While in New Zealand for three months, one of the top questions I was continually asked (right after ‘How do you like New Zealand?’ Answer: ‘I love everything about it except your crazy roads and drivers!’) was, ‘So what do you think of Obamacare?’ My answer was, and continues to be, ‘Good and bad things, but it’s at least a step in the right direction.’

New Zealanders, along with citizens of all other industrialized countries, don’t understand how we Americans tolerate our crazy health care system. Consistently, New Zealanders I spoke with told me they don’t ever really think about health care, and especially not about health insurance. They pointed out that their choice of jobs isn’t tied to health insurance coverage. They have guaranteed basic health care coverage for all citizens, or ‘universal health care,’ through their Ministry of Health. People in New Zealand have the option of purchasing additional private health insurance to help speed up access to things like hip replacement surgeries, but it’s mainly affluent older people who take that option. New Zealand has a centralized national pharmaceutical agency, Pharmac, in order to keep drug costs down. U.S.-based large pharmaceutical companies continue to try and block Pharmac. And they have a national, comprehensive, no-fault personal injury coverage system, the Accident Compensation Corporation (ACC), that covers New Zealand residents as well as visitors. ACC also covers instances of medical malpractice/liability: people in New Zealand cannot sue their health care providers or hospitals.

In terms of life expectancy, in the Health Olympics, New Zealand ranks #16, coming in just after the Netherlands. The U.S. ranks #34 right before Qatar. According to a 2011 Commonwealth Study (The US Health System in Perspective: A Comparison of Twelve Industrialized Nationsby David Squires), New Zealand spends almost one-third less per person on health care than we do in the U.S. ($2,683/person/year versus $7, 538/person/year). Obviously, New Zealand is a much smaller, less diverse country than the U.S., and no health care system is perfect, but their health care system blows ours out of the Pacific waters.

It is interesting to note that the (Republican) Harvard Business professor Michael E. Porter’s new Social Progress Index of overall livability ranks New Zealand No. 1, and the U.S. No.16 (and he ranks the U.S. No. 70 in health). See Nicholas Kristof’s NYT op-ed piece We’re Not No. 1! We’re Not No. 1! (April 2, 2012).

The photo this week is of me on a home visit in Hobbiton, New Zealand. This is a community where hobbits manage to live very long and healthy lives, despite the fact that they have high rates of smoking and drinking and eating of high-fat foods. How do they do that?

The Intima: A Journal of Narrative Medicine

Cultural Safety: A Wee Way To Go

DSC01879 - Version 2DSC01418This week I had the good fortune of meeting with Denise Wilson, RN, PhD, a Maori New Zealand nurse and Director of the Taupua Waiora Centre for Māori Health Research at AUT School of Public Health and Psychosocial Studies here in Auckland. She talked about her work with cultural safety in New Zealand.

Like many indigenous peoples across the world–including our own in North America–Maori cultural conceptions of health and well-being tend to be much more holistic and less individualistic than mainstream Western ones. As Ms. Wilson explained, for most Maori patients she has worked with (clinically and in research), spirituality and connection with their land and extended family are the most important aspects of health. The Maori word for land, Whenua, also means placenta: it is what nourishes you. The history of colonialization, and being displaced from ancestral lands, have had profound negative effects on Maori health and well-being.

The term ‘cultural safety’ came from a Maori nursing student, Iriphapeti Ramsden (1946-2003), who in the early 1980′s stood up in class one day and asked something like, “We talk about patient safety, physical safety, and ethical safety, but what about cultural safety?” She was specifically referring to the difficulties Maori patients and their families (as well as Maori nursing students such as herslef) have within the Eurocentric health care system in New Zealand. These difficulties continue to contribute to New Zealand’s large health inequities and low representation of Maori nurses and other health care providers in the healthcare system. Ramsden went on to receive her PhD, developing the concept and practice of cultural safety. I discovered that Dr. Ramsden was part of the New Zealand feminist Spiral Collective, which ‘self-published’ Maori writer Keri Hulme’s book The Bone People after it was rejected by all major publishers. The Bone People, of course, went on to win the Man Booker Prize. One of my all-time favorite books, I assigned it as our New Zealand study abroad Common Book this quarter.

According to Denise, a culturally unsafe practice is “anything that diminishes, demeans, or disempowers the cultural identity and well-being of an individual.” A culturally safe or unsafe practice is determined by the patient and the patient’s family (another form of what we term in the U.S. ‘patient-centered care.’) Denise told me that a good ‘cultural safety’ question nurses can ask patients (and their family members) is, “What are things that are really important to you that we need to consider in your care?” Cultural safety includes an emphasis on self-reflection (and action) by the nurse in terms of understanding his or her own cultural and social attitudes that affect their care of patients and communities.

Cultural safety has been taught in New Zealand nursing programs for over twenty years. Since 1992 it has been a requirement for nursing and midwifery registration examinations. What started off as a bicultural focus (Maroi and Pakeha/non-Maori), has been expanded to include things like migrant status, gender/sexual orientation, socio-economic ‘class’ status, and disability. The concept of cultural safety has been adopted by regions in Australia, Canada, and the United States. Denise acknowledged the significant advances that have been made in New Zealand in terms of cultural safety, but she concluded with: “We do have a wee way to go.”

Cultural safety seems to have much in common with my favorite U.S. ‘cultural’ concept of cultural humility, which I have written about in a previous post. Cultural humility was developed as a concept by the African-American physician-nurse duo Tervalon and Murray-Garcia in their 1998 article, “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. (Journal of the Poor and Underserved, 9(2) 117-125. Since then, the practice and concept of cultural humility have been further refined. Cultural humility emphasizes: 1) a commitment to lifelong learning and critical self-reflection, 2) recognizing and changing power imbalances, and 3) developing institutional accountability. Take a look at the excellent 30-minute video Cultural Humility: People, Principles and Practices by San Fransisco State professor Vivian Chavez.

Even closer to (my) home of Seattle, the historical roots and “remnants of our unresolved past” of racism and classism are powerfully presented in Shaun Scott’s short documentary A Really Nice Place to Live. In the film, Shaun Scott points out that Seattle is a byproduct of White Western Frontierism. He references historian Richard Drinnon’s work on the ‘Metaphysics of Indian-Hating,” where Drinnon asserts that all of American’s domestic and international race and class dynamics can be traced back to our original interactions with our ‘own’ Indigenous peoples.

We all have a wee way to go in terms of addressing and redressing the effects of racism and classism and all the other ‘isms’ of the world.

******************************

The first photograph here is of the friendly and informative staff at the Alliance Health booth at Auckland’s annual Pasifika Festival, which I attended this past weekend. The staff members were promoting community awareness and prevention of rheumatic heart disease. New Zealand has the highest prevalence of rheumatic heart disease of all industrialized countries, and the highest rates are among Maori. It is a result of untreated ‘strep throat’ and is considered a disease of poverty. One of their community-led ‘interventions’ was the creation of Mama’s House as a culturally-appropriate way to engage the Pasifika community.  “Knowing that mothers, sisters and aunties are the first port of call about all matters relating to family health and well-being. After all, ‘Mama knows best’.” It also happened to be International Women’s Day. (And I also had just played ‘Mama-Nurse’ for some of my students who had developed penicillin- resistant strep throat, resulting in some ‘interesting’ interactions with the New Zealand healthcare system, which–like our own–has ‘a wee way to go.’)

The second photo is an interactive game show called “The Survivors,” part of the Maroi section of Wellington’s excellent Te Papa Museum exhibition Slice of Heaven: New Zealand’s Twentieth Century History. As this photo shows, one of the decisions you have to make while playing the game is whether you (as a Maori young woman in the 1970′s) went to the shorter/cheaper nurse aid program or to the longer/more expensive (and heavily Pakeha/’White European’) program to become a Registered Nurse.

Green Beyond Death

indexThis is a shout-out to the work of a former nursing student of mine, Hunter Marshall. He is now a hospice nurse, as well as an environmental and death with dignity advocate, community activist–and a  talented writer! Check out his recent article “Dying to give back to the earth” in Waging Nonviolence (3-3-14).

Hunter told me that he is actively pursuing writing as a mechanism for continuing his patient/policy advocacy: “I particularly enjoy using narratives about individuals that intersect with larger policy issues.” Another rebellious nurse (and writer) in the younger generation warms the cockles of my older nurse/writer heart!

Misogyny In Sheep’s Clothing (with a G-String)

DSC01009I preface this by saying: I know the Biblical quote that it’s easier to see the speck in another person’s eye than to see the plank in your own. In the U.S. we have a lot of work to do in terms of overcoming misogyny in all it’s ugly forms (including commercial sex trade/exploitation or perhaps even all the books by Philip Roth?) We have a very large plank, especially in places like Nevada.

But I have to say that one of the most surprising things I’ve learned while in New Zealand these past months is the country’s level of violence against women. Before coming here I mainly knew that New Zealand was rightly proud of the fact that it was the first country in the world to give women the right to vote (in 1893). I also knew that there was a healthy cadre of New Zealand feminists at work influencing national policy through research, direct service, and the arts. What I had not realized was how deeply ingrained the sexism is here, perhaps as yet another direct descendant of British colonialism? That is what one of my Maori female informants and experts on this topic asked somewhat rhetorically. I had not realized that prostitution is legal in New Zealand (the photo here is of the Calendar Girls strip club/’gentleman’s club/brothel left standing in the Red Zone of Christchurch.) I had not realized that New Zealand is one of the worst industrialized countries in terms of violence against women. (See: Facts on Violence Against Women, by Janet Fanslow, New Zealand Herald, 11-25-11.)  Of course, those are all interrelated.

A society’s level of sexism and misogyny, plus tolerance of violence, plus racism, plus poverty, plus sexualization of girls, plus a high level of commoditization and commercialism, are all documented risk factors for commercial sexual exploitation (CSE) of girls and women. Additional environmental risk factors for CSE include: open presence of the adult sex industry, transient male populations, and proximity to borders/ports.

I have spent many decades as a nurse working with homeless and prostituted teens and young adults on both coasts of the U.S., as well as in Thailand. There was a time during the early part of the HIV/AIDS epidemic when I bought the idea of sex trade as potentially being empowering work for women, along the idea that legalizing and regulating (including health screens) prostitution/sex work was a good thing. But that belief was short-lived when I realized how dangerous the work is, no matter how ‘upscale’ or regulated or sanitized. And when I realized (from both credible research reports and stories from young women I worked with) that the women and children in prostitution anywhere in the world come from the most marginalized and oppressed groups in society. And how many (upwards of 90% in many studies) have untreated PTSD and histories of sexual abuse as children. And there is mounting evidence that legalizing prostitution only increases human/sex trafficking.

Efforts like those in my home state of Washington to decriminalize prostitution for the women/men/girls in sex work (and refer them to appropriate services), while simultaneously stepping up the severity of prosecution of the buyers (‘Johns’) and the traders (‘Pimps’), make the most sense to me. Meanwhile, Nevada has counties near places like Las Vegas where prostitution is not only legal. They lock up women inside barbed-wire secured brothels called ‘ranches,’ and then busloads of ‘customers’ arrive to be serviced. Like I said, we have planks in our own eyes.

Nurses and other front-line primary care providers need education and training in how to identify and effectively work with children and adults involved in CSE. Similar to gaining skills in working with victims of intimate partner violence, any screening or intervention is based on building rapport, maintaining appropriate professional boundaries (including not ‘rushing in to the rescue’), understanding PTSD and trauma bonding, using the principles of harm reduction to help the client build a safety plan, and knowing good community resources for appropriate referrals. One important health component I’ve found to be essential is having culturally-clued in positive body work (like yoga) to refer people to. It helps them get cued in to what the body can do, instead of what is done to the body/body as object. And for anyone who doesn’t know how to ask a patient about this topic, here’s the standard screening question: “Have you ever traded sex for money or other things needed to survive?”

And remember the words of Gloria Steinam: “Prostitution isn’t the world’s oldest profession. It’s the oldest oppression.”

Resources:

Polaris Project: For a World Without Slavery

The Washington Anti-Trafficking Response Network: 206-245-0782

National Center for Missing and Exploited Children: 1-800-THE-LOST

National Human Trafficking Resource Center Hotline: 1-888-373-7888

An excellent 5-minute training/education video about the process of ‘grooming’ that can draw young women into prostitution: GEMS The Making of Girl.

Disaster Preparedness: Lions and Tigers and Zombies and Earthquakes, Oh My!

DSC01509There are many things to worry about in this world. For instance, right now in my hometown of Seattle, the Alaskan Way Viaduct is sagging a bit due to the large-scale drilling going on in the downtown area. The Alaskan Way Viaduct is built on ‘reclaimed land’ from Puget Sound that would most likely turn to liquefaction in our next earthquake (similar to what happened in the Christchurch earthquakes). But OK—state officials say it’s nothing to worry about.

As I write this post I am sitting on a ‘somewhat active’ series of volcanoes, on land that was covered in a hot mud eruption only ten years ago. Rotorua, on the North Island of New Zealand is a hot mess. The youth hostel we are staying in has fire action directions in each bedroom, but no information about what to do in case of an earthquake–or a volcanic eruption.

Disaster preparedness and effective disaster messaging are important components of public health. In the U.S., disaster preparedness communications specialists came up with the  Zombie Disaster Preparedness Campaign. Supposedly this campaign started out as a joke by a CDC communications specialist frustrated over the lack of public interest in their traditional disaster preparation information. But then the Zombie Campaign became so effective they’ve continued to use and expand upon it. This shows that with the ‘Chicken Little’ dire warnings of impending doom, a little levity can help.

Last week in Wellington, we talked with Sara McBride, a PhD candidate at Massey University at the Joint Center for Disaster Research. (The photo here is of the inside of their Emergency Operations Center where they coordinate disaster response for the university and conduct trainings). Her area of expertise is as a risk communicator, work which she was doing in Christchurch before the earthquakes. She told us that disaster communication is tricky because too much emphasis on doom and gloom results in people becoming fatalistic. Ms. McBride is currently doing research and work on earthquake/disaster preparedness and messaging in Washington State (where she grew up). As Professor Timothy Melbourne writes in his guest editorial in today’s Seattle Times, the Seattle area is at high risk for major earthquakes and tsunamis on the scale of those in Japan three years ago (“What Our Region Has Not Learned from the Japan Earthquake and Tsunami, 2-25-14). He points out that Washington State needs an honest and transparent assessment of building safety (and other structures such as our dams and bridges). This is an excellent ‘health in all policies’ topic for nurses to get involved with.