The Travelator of Racism

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

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

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

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

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

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

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


Falling Off the Funding Cliff of Good Health

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

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











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

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

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

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

Shame on Anti-vaccinators

IMG_3414A few years ago I wrote a blog post “Nurses and Anti-Vaccination” (6-4-12). The post stirred up some interesting and impassioned reader comments.  I said then that as a health care provider I consider it my professional duty to stay current on recommended vaccinations, including the annual flu vaccine. I still believe that. In fact, I’ll extend it to state that I believe it is a basic ethical and civic duty for everyone within a community to stay current on recommended vaccinations–unless they have valid medical reasons for an exemption. And, it is a basic duty of our public health/ health care systems to ensure equal access to safe and affordable vaccines.

With the current mutli-state serious measles outbreaks caused by anti-vaccinator parents opting out of vaccinating their children (and then taking them to Disneyland), there seems to be growing public sentiment in favor of stricter vaccine regulations. An important aspect of this ‘hot topic’ which is left out of most news reports, is the fact that it is mainly affluent, educated, white parents who are the anti-vaccinators. They typically believe in everything ‘natural,’ including how natural it is for small children to get really sick (and die) from ‘natural’ childhood communicable diseases. For the truly paranoid/OCD, this would be yet another good reason to never shop at Whole Foods, since I am convinced their shoppers have some of the highest rates of anti-vaccination anywhere in a community.

But on a less strident note, I do understand that anti-vaccinators (parents or otherwise) are not evil or stupid–and that it does no good from a practical and public health perspective to try and shame them into changing their minds. As I teach my nursing students, in approaching this topic with friends, family members, and patients, it is helpful to step back and use positive communication techniques from motivational interviewing–of establishing basic respect first, then exploring the motivations, fears, and beliefs behind the action. Only then can possible positive changes occur.

This past year, Eula Biss’ book On Immunity:An Innoculation (Graywolf Press 2014) addressed the issues related to anti-vaccination. I had high hopes when I first purchased her book and began to read it. While the book is well-written and mostly a pleasure to read, it was almost too easy to read. It felt more like I was eavesdropping on informal chatty banter from a neurotic new mother, albeit from an intelligent (and likeable) neurotic new mother. And while I understand her choice to not include real citations/footnotes for sources, that made me not trust many of the things she claimed to be ‘facts.’ I got really annoyed with how many times she inserted random quotes from her oncologist father. Other quotes/comments she included from various ‘experts’ seemed to be straight out of Frontline’s ‘video ‘The Vaccine War’ from 2010. Frontline’s website is an excellent and more updated resource for discussion and education on this topic. Michelle Dean posted the interesting piece ‘A Q&A With Eula Biss’ with further insights into why she wrote the book (Gawker Review of Books, 9-30-14).

The national debate on vaccination continues. Epidemiologist Saad B. Omer from Emery University wrote an important NYT op-ed piece “How to Handle Vaccine Skeptics” (2-6-15) advocating for policy-level changes to address high ‘opt-out’ rates. And poor Mississippi even made the news recently in conjunction with this topic: they have among the strictest state vaccine ‘opt-out’ laws and “the country’s highest immunization rate among kindergartners.” (Alan Blinder, “Mississippi: A Vaccination Leader, Stands By Its Strict RulesNYT, 2-4-15).

A Photo Ode to Harborview

This week I have been immersed in both the history and present state of the health care safety net in my home town of Seattle, especially as it is ‘embodied’ (or ‘em-building-bodied’) by Harborview Hospital/Medical Center.

Harborview is the largest hospital provider of charity care in Washington State. It serves as the only Level 1 adult and pediatric trauma and burn center, not only for Washington State, but also for Alaska, Montana, and Idaho, a landmass close to 250,000 square kilometers with a total population of ten million people. In addition, Harborview provides free, professional medical interpreter services in over 80 languages, and has the innovative Community House Calls Program, a nurse-run program providing cultural mediation and advocacy for the area’s growing refugee and immigrant populations.

Here is my photo–simple ode–to Harborview and its adjacent Harbor View Park:

Behold, the shining beacon on the hill,

IMG_3317 - Version 2









Rising from marshland’s King County Poor Farm,








Stalwart Sisters of Providence did till,

IMG_2629 - Version 2











Shielding paupers, ill and homeless from harm;

Then, to separate church from state, we care,

‘Above the brightness of the sun: Service,’

Proclaimed the poster on opening day;








Now, our common humanity declare

Responsibility to resurface,

Embrace compassion for all, we say.



Ten Neglected Classics of Nursing Literature

IMG_2631Recently, The American Scholar had an article by their editors entitled “Ten Neglected Classics” (1-13-15).  As they state, “…the following books are works we think ought to be read by more people, works that we keep coming back to but aren’t talked about as much as we would like.” This article got me thinking about what books I would include on my list of ‘ten neglected classics of nursing literature.’

I quickly ruled out any and all of the Cherry Ames series. I did not grow up wanting to be a nurse and I never read any of the Cherry Ames nurse series until……okay…true confession: I have never been able to read any of the Cherry Ames books. But I do own one (the photo here is of the cover of the book I own, a 1948 edition of Cherry Ames Cruise Nurse, by Helen Wells). The concluding sentence of the book is the oh so enticing cliffhanger: “And somehow  she knew that although the cruise had come to a happy ending, her friendship with young Dr. Monroe had only just begun.” Someone should write a modern-day feminist kick-ass version of Cherry Ames , or perhaps a lesbian soft-porn version….. But I digress.

Any list of classics, including my list of Top Ten Neglected Classics of Nursing Literature, is highly subjective. Here are my inclusion criteria: 1) about nursing or have a strong lead character–or a strong and memorable character– who is a nurse; 2) books or at least novella-length works; 3) books/works I have read and have in my personal library to refer back to frequently; 4) are still in print/easily accessible; 5) be well-written enough and of wide enough appeal (as in not in a nursing ghetto) to be called literature; 6) not be by or about Florence Nightingale. Oh. I broke that last rule. The term ‘classics’ is also highly subjective, and I include books that have already stood the test of time, as well as more recent books that I believe will stand the test of time.

Here they are:

1) One Flew Over the Cuckoo’s Nest by Ken Kesey. Includes the legendary character of Nurse Ratched. I’ve written about her in a previous blog post ‘Nurse Ratched’s Backstory’ (7-16-13). I love Nurse Ratched.

2) God’s Hotel by Victoria Sweet. Even though this book is mainly about physicians and hospitals, it also includes strong and memorable nursing figures, such as the hospital matron who knitted blankets for her patients.

3) Call the Midwife: A Memoir of Birth, Joy, and Hard Times by Jennifer Worth. There are three book in this series but the first is by far the best.

4) The Beautiful Unbroken: One Nurse’s Life by Mary Jane Nealon.

5) Critical Care: A New Nurse Faces Death, Life, and Everything in Between by Theresa Brown.

6) I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse, edited by Lee Gutkind. Note: even though I have an essay included in this anthology, I do not receive any payment from sales of the book.

7) On Being Ill by Virginia Woolf along with Notes From Sick Rooms by (Virginia’s mother who was also a nurse) Julia Stephen.

8) Eminent Victorians (chapter on Florence Nightingale is hilarious and enlightening about this complex person) by Lytton Strachey.

9) Between the Heartbeats: Poetry and Prose by Nurses, edited by Cortney Davis and Judy Schaefer.

10) _______________________ I racked my brain and tore up my bookshelves in search of a tenth book worthy of being included in my list, but I have yet to find one. Please add your recommendations/nominations.

What Happens To a Dream Deferred?


Baltimore Street Corner. Photo credit: Josephine Ensign 1992

The title of this blog post is the first line of Langston Hughes’ powerful poem ‘Harlem.’ NYC-based poet/novelist, teacher, and photographer Don Yorty has made an excellent short video/reading of ‘Harlem’ linked here.

I recognize that it is a bit ‘too politically correct’ and in a way even cowardly to be a white person writing about the persistent problem of racism in the U.S. on the official Martin Luther King, Jr. government holiday. It’s not as if the topic of racism–of having conversations about racism–should occur in ‘polite’ (as in white) company on only one day of the year. Racism is, of course, back in the national spotlight due to the 2014 high-profile cases of race-based police brutality in Ferguson and beyond. I’ve written about the intersection of racism and health in previous posts, most recently in “Virginia Relics Part One: Racism” (9-15-14). Last year when I was teaching community health in New Zealand and learning about their indigenous Maori population and racism, I wrote a post “Cultural Safety: A Wee Way To Go”  (3-12-14). In that post I included information and links to two wonderful video resources I use in teaching about racism: 1) Cultural Humility: People, Principles and Practices by San Fransisco State professor Vivian Chavez; and 2) Shaun Scott’s short documentary A Really Nice Place to Live (about the historical context of racism in Seattle). I use these videos in combination with the excellent PBS series Unnatural Causes‘ episode “When the Bough Breaks,” which highlights the serious health effects of racism on African American women and their infants. Together, these three videos help spur important (and oftentimes emotionally-charged) classroom discussions about racism.

Happy (thoughtful, reflective, peaceful) MLK Day.


  • A good and clearly-written article “Why There’s No Such Thing as Reverse Racism” (Daily Kos, by ‘hepshiba’ 7-15-2010). Helps to clarify that thorny and oft-quoted statement that black people can’t be racists.
  • Anything by Dr. Camara-Jones of the CDC. Especially her cliff analogy of determinants of health/where racism comes into play (low-budget but good video of it here); and her Gardner’s Tale/three levels of racism (video of it here).