The Health Humanities Consortium

logo-1This relatively new group has provided a breath of fresh air in my life, as they manage to blend a not-overly-stuffy academic grounding with all the passion, creativity, and ‘meaning of life’ that the humanities has to offer. I’ve recently returned from their second annual conference and these both have easily been among the best conferences I’ve ever attended (and being an academic-type, I have been to numerous conferences). Great people doing great and important work to try and humanize health care and health professions education.

From their fresh-off-the press website:

“About: The Health Humanities Consortium is a community of scholars and institutions who work in the humanities and arts to promote, reflect on, and advocate health and health care in the world.”

Source: About

Place-based Health and Well-being

P1010527If you have to be poor and homeless, don’t be poor and homeless for long. If you have to be poor and homeless, learn how to fill out all of those food, health, and housing support forms before you become poor and homeless. If you have to be poor and homeless, chose carefully which city to be poor and homeless in.

That’s my take-home message from this past week’s top public health news stories, as well as from my recent trips to the underbellies of both Los Angeles and Cleveland. If I somehow were to become poor and homeless again, I would want to be poor and homeless in my adopted hometown of Seattle. Seattle has its problems, but as a major U.S. city, we somehow manage to do many things right.

First, the buzz created among health policy-minded people and even laypersons from a recent article in JAMA reporting research results indicating that individual health behaviors like smoking and lack of exercise among poor people in the U.S. are the most important correlates of their diminished life expectancy compared with higher income people.

The April 10, 2016 JAMA article, “The Association Between Income and Life Expectancy in the United States, 2001-2014” by Stanford University economist Raj Chetty and associates, used an impressively large dataset of 1.4 billion deidentified tax records; Social Security Administration death records; rates of self-reported smoking, obesity, and exercise from the CDC’s Behavioral Risk Factor Surveillance Survey; Medicaid claims data; national/regional data on major urban ‘commuting zones,’ urban area per capita government spending, fraction of the local population that are college graduates, average housing price, and level of socio-economic neighborhood segregation. The researchers claim to have found weak to no correlations between life expectancy and many of the classic social determinants of health, while finding a strong correlation between individual health behaviors (especially smoking) of the poor and life expectancy. Although, in digging into this quite dense article, it becomes apparent that being poor in some urban areas and regions of our country is much worse than in others. The 10 states with the lowest life expectancy for the poorest people form a belt across our country: Michigan, Ohio, Indiana, Kentucky, Tennessee, Arkansas, Oklahoma, and Kansas. Their data indicate that it is much better to be poor if you live in urban areas of California, New York, or Vermont. And they report that the strongest protective factors for people people include the percentage of recent immigrants (long known to be healthier when they first arrive to the U.S. but we somehow beat the healthy living out of them), higher local government expenditures per capita, and the fraction of the local population with college degrees.

Life expectancy was not shown to vary by access to most health care, but it was positively associated with level of preventive care. The level of residential segregation by socio-economic level mainly negatively impacted the life expectancy of people in the top income bracket. That finding should be getting much greater emphasis in the press: to all the richie-rich people who live in gated communities, believe in trickle-down economics, and do everything they can to avoid (or to invest in) impoverished areas near where they live, are paying the price by shortening their own life expectancies–and the life expectancies of their family members.

But it is important to read and digest the JAMA editorial in the same issue, “The Good Life: Working Together to Improve Population Health and Well-Being” by Steven H. Woolf and Jason Q. Parnell. As they astutely point out, the Chetty study has several major flaws (that, not surprisingly, were largely unnoticed and ignored by mainstream media). First, the researchers of the Chetty study used life expectancy at age 40 years instead of the more usual and robust life expectancy at birth. They also excluded people with no reportable income on federal taxes (thus, most all people experiencing homelessness), and they excluded people who live in rural or urban/commuting areas of less than 590,000 persons. Woolf and Parnell also point out that the Chetty, et al research report–and the way the researchers structured the study–“ignores both upstream determinants of individual health behaviors and the poor measurement of other pathways.”

Woolf (a physician) and Parnell go one to claim “that everyone seeks a good life,” of which health is an essential component, “but a good life also involves productive work, emotional and spiritual well-being, supportive social relationships, and a clean and safe environment. (…)  Inequity, a term that can engender political controversy, is giving way to the language of opportunity and the more positive, bipartisan message that everyone deserves a fair chance at the American dream. Education is seen as an answer, not only for better health but also to combat poverty, crime, racism, the loss of blue-collar jobs, and many other social challenges. Many sectors are targeting early childhood, a pivotal age to shift life trajectories, giving children tools for success in education and careers and breaking the cycle of poverty while also preventing illness, behavioral disorders, substance abuse, and violent crime.” Woolf and Parnell exhort their (mainly) physician readers to use their “gravitas” to advocate for local improvements in the social determinants of health. They (annoyingly) leave out the essential role of nurses and all other members of the health care team. But, okay, it is JAMA after all.

Chetty was a researcher on an earlier study on variations in upward mobility of children growing up in different urban areas. In a July 22, 2013 NYT article, “In Climbing Income Ladder-Location Matters,” David Leonhardt used the study’s findings to compare children’s income mobility if they lived in Seattle versus Atlanta (at the time, the two cities had similar median incomes). Leonhardt writes, “The gaps can be stark. On average, fairly poor children in Seattle — those who grew up in the 25th percentile of the national income distribution — do as well financially when they grow up as middle-class children — those who grew up at the 50th percentile — from Atlanta.” The researchers of this study outlined four main factors which were linked with upward mobility for children growing up in poverty: 1) living in less socio-economically segregated neighborhoods, 2) living in a two-parent household, 3) access to better public elementary and high schools, and 4) higher levels of civic engagement, including in religious and community groups.

I leave you with some uplifting, positive, encouraging (and yes, nurse-centric) news related to this topic. The cost-effective, evidence-based Nurse-Family Partnership program is again in the news. I’ve written about this amazing program before (see “More Babies! Nurse-Family Partnership” January 29, 2012). The New Yorker, in a March 1, 2016 post titled “One of the Stranger Jobs in Texas,” links to a recent “The New Yorker Presents” film by Dawn Porter titled “Lone Star Nurse.” The film follows the work of former teen mother turned public health/ Nurse-Family Partnership nurse Nicole Schroeder as she visits “her girls” in Port Arthur, Texas. I say we need many more Nurse-Family Partnership nurses like Schroeder and much fewer high-end, elective surgery hospital nurses. Just saying…

 

 

 

High Art, High Medicine, High Lead

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Woman looking at art, Cleveland Museum of Art. Photo credit: Josephine Ensign/2016

Cleveland: the city of high art, high medicine, and high lead levels. Home of the amazing Cleveland Museum of Art, with its recent $350 million renovation, including a glass-enclosed atrium, the city’s largest free public space (at 39,000 square feet).

I spent the past week living in Cleveland, Ohio, in a hotel next to the Cleveland Clinic Hospital, one of our country’s premier high-end, high-tech medical complexes. It is, of course, a private health care entity. The last time I visited the Cleveland Clinic was in 1979 when I was a (blessedly only briefly) ‘cardiac patient,’ referred there by my Oberlin College clinic physician for a bothersome heart rhythm problem–probably precipitated by too much caffeine and studying of medical ethics. I remember being inside a dark brick building, and if the clinic space back then had any artwork to speak of, I certainly don’t remember it.

A few days ago, touring the art collection in the main Cleveland Clinic Hospital and guided by one of their art program curators, I was struck by how much of it is cold, clinical, and high-tech–matching, I was told, the overall branding image of the hospital system. I was standing inside the hospital space where surgeons recently had performed the first U.S.-based uterus transplant (significantly, I believe, in a married, Christian white woman and mother of adopted sons). Here are a few examples of the hospital’s prickly artwork:IMG_6708

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‘The Ineffable Gardener and the Developed Seed” 2013, Stainless steel modules, by Lois Cacchini.

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Untitled (Rooftop View) oil on masonite, 1957, by Hughie Lee-Smith. Cleveland Art Museum. 

Cleveland is part of the Rust Belt now, and the town’s numerous boarded-up, crumbling factory buildings and houses are testament to the city’s economic decline. Cleveland is a city of 389,524 residents, the vast majority are African-American, and 39.2 of all residents live in poverty (the median household income is $24,701). Not surprisingly, the health care sector is Cleveland’s largest employer, with the arts also being a leading industry. (Source: Data USA from the MIT Media Lab–a great source of up-to-date and easy-to-use data visualization based on US government databases.)

When I checked into the Cleveland hotel at the start of my health humanities conference, a middle-aged white man from Germany was carrying a large container of bottled water. When I asked him about it he told me he’d read that Cleveland’s water supply was not safe and contained high lead levels, so he was buying his own water. He also told me he had flown in to be treated at the Cleveland Clinic.

Indeed, Cleveland has one of our nation’s worst problems with lead ‘poisoning’ but mainly from lead paint in deteriorating inner-city housing. The Cleveland neighborhood of Glenville, only blocks north of the Cleveland Clinic, had a 2014 study of lead levels in children under age 6 showing that 26.5% had levels exceeding the current CDC threshold of 5 micrograms per deciliter. (Source: NYT article “Flint is in the news, but lead poisoning is even worse in Cleveland” by Michael Wines, March 3, 2016.)  Lead, as we know quite well by now, at any level is a brain poison that permanently decreases IQ and interferes with a person’s ability to control impulses. A different spin on the “No Child Left Behind Act.”

This photograph, taken from the top floor of the Cleveland Clinic Hospital and looking north towards Lake Erie, shows the downtown skyline to the left, and to the right (the darker, low-lying area) is the Glenville neighborhood. As I stood gazing at the Cleveland skyline from atop this very antiseptic and removed private hospital, I couldn’t help but wonder how anyone can possibly believe in trickle-down economics. To me it is the ultimate of self-serving delusions. IMG_6715

Down and Out in L.A.

IMG_6660Los Angeles, what with its population of over 40,000 people who are homeless and with the nation’s largest concentration of chronic homelessness, is an interesting (and distressing) city to live in. Or to visit. Unless you limit yourself to staying within the sanitized realms of either Disneyland or La-la Hollywood-land.

I was in downtown L.A. for four days recently to attend a national writers conference, but also to see if I could get some sort of context to the problem of homelessness in this giant car-centric sprawl of city–a city like no other. Not being from Los Angeles, it is difficult to decipher what is real and what is just another stage set. Where else would Don Draper (Jon Hamm) of Mad Men saunter through a writers conference and serve as guest editor for a literary magazine’s special edition on advertising writing? (Yes, this really happened, and yes, he is even more handsome in person.) And where else would car crash scenes complete with dazed people staggering around with bloody heads happen right outside one’s hotel? (Yes, this really happened as I was trying to walk from my hotel to an art museum–I almost stepped in to help out with the human carnage before I realized it was actually a stage set.)

On my first day in L.A. I noticed these curious ‘private property’ bronze plaques all over the sidewalks. They basically say, “Move along all you tempest-tossed tired and homeless. Move along. You don’t belong here.”

 

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And these homeless- deterring benches at bus stops. Although–look closely–this one comes with its own food pantry. A man pushing a shopping cart nearby who stopped to inspect these cans told me that people drop off food for the homeless and that cans of vegetables don’t get picked up very quickly. He happens to like vegetables and took all the cans.IMG_6614 I had arranged to do a site visit at the Homeless Health Care Los AngelesCenter for Harm Reduction in the heart of Skid Row in downtown Los Angeles. The director, Mark Casanova, graciously gave me a tour of the facility and talked with me about their work. I’ve visited the Insite safe injection center in Vancouver, BC, so I thought I knew what to expect. Insite is North America’s first and only legally-sanctioned safe injection site and syringe (‘needle’) exchange, although several cities in the U.S.–including my hometown of Seattle–are considering opening one to help address the current heroin epidemic. (See Seattle Times article, “Heroin, cocaine users in Seattle may get country’s first safe-use site,’ by Daniel Beekman, April 4, 2016 for more information.)

 

IMG_6656Visiting the L.A. Center for Harm Reduction with Casanova while it was in operation was an eye-opening experience for me even though I have long been ‘sold’ on the concept and practice of harm reduction: treat people in a non-judgemental and respectful manner and work beside them to find ways to minimize harm to themselves and to other people. From a public health perspective we know that this approach works to save lives and protect everyone’s health.

The eye-opening part was mainly the sheer scale of the need for services such as those provided by the Center for Harm Reduction. They have a syringe exchange that must be one of the largest in North America in terms of quantity of ‘needles’ exchanged. They serve an average of 145 people per day. They also have an on-site wound care clinic and soon will add an on-site drug treatment program. And they have a very successful overdose prevention program where they train clients in the proper use of Naloxone (also known as ‘Narcan’), a non-addicting prescription drug that temporarily blocks and reverses the effects of opioids (prescription opioid pain medications, as well as heroin). Naloxone is available in either an injectable form or a nasal spray. So far, the Center for Harm Reduction, through their own on-site staff and through their street-based program, have prevented over 400 overdose deaths. Here is a photo of the current map showing their overdose reversals. Remember, one of these lives saved could have been your daughter, son, friend, etc.

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Notice the sign in the photo below, asking clients to report police harassment, especially in terms of confiscation of either their syringes or Naloxone/Narcan. Los Angeles has a problem with criminalizing homelessness. Not just with bizarre ‘Private Property’ bronze sidewalk signs and with arrests for and confiscation of drug paraphernalia,  but also with a limitation on the ‘size’ of homeless rough sleepers’ personal belongings. The day before I toured the Center for Harm Reduction, L.A. City Council had just passed a resolution limiting the rough sleepers to whatever personal items (including tents, blankets, sleeping bags, clothing, and food) to what can fit into a 60 gallon container. They say the rest will be confiscated and destroyed. IMG_6618

On a much happier, up with people note, I was impressed by the fact that the Center for Harm Reduction has a companion Healing, Arts and Wellness program next door where they provide space for arts and writing programs, karaoke, a lending library, yoga, acupuncture and cranio-sacral treatment, Zumba fitness classes, and life-skills training. Here are some of my photographs of this very health-promoting space and artwork by participants. Thank you Mark Casanova and all the wonderful staff of Homeless Health Care Los Angeles for all the important work you do.

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Home is…

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Community blue tarp tapestry/ Soul Stories project. Photo credit: Josephine Ensign, 2016

Home-less-ness. Un-homed. Being without “a fixed, regular, and adequate nighttime residence.” 

Where did you sleep last night? Was it in a warm, dry, and safe place?

If you were asked to summarize the essential meaning of home to you in one word or in a brief phrase, what would it be?

As human beings we have to have rest–and sleep–in order to not only thrive, but survive. Sleep is the ultimate letting go and trusting that we will not be disturbed, that we will be okay until we awaken. The trust we have through undisturbed sleep generates hope.

What does it mean to be homeless when home was never a safe place? In such cases, it is not possible for young people to ‘runaway’ from home; they can only run towards home.

Housing, ‘home-ing,’ is a form of health care. The people at the National Health Care for the Homeless Council summarize this connection with the following:

  • “Poor health (illness, injury and/or disability) can cause homelessness when people have insufficient income to afford housing. This may be the result of being unable to work or becoming bankrupted by medical bills.
  • Living on the street or in homeless shelters exacerbates existing health problems and causes new ones. Chronic diseases, such as hypertension, asthma, diabetes, mental health problems and other ongoing conditions, are difficult to manage under stressful circumstances and may worsen. Acute problems such as infections, injuries, and pneumonia are difficult to heal when there is no place to rest and recuperate.
  • Living on the street or in shelters also brings the risk of communicable disease (such as STDs or TB) and violence (physical, sexual, and mental) because of crowded living conditions and the lack of privacy or security. Medications to manage health conditions are often stolen, lost, or compromised due to rain, heat, or other factors.”

For those of us fortunate enough to be currently housed and ‘homed’ in a ‘fixed, regular, and adequate [and safe] nighttime residence’–for those of us who are able to have adequate, safe, undisturbed, restorative-of-hope sleep–let us all remember (or imagine if we’ve never experienced it) what it is like for people who go without these essential human needs. And let us use our rest, our trust, our hope to fix this ‘wicked problem’ of homelessness.

___________

Notes:

  • The blue tarp tapestry shown in this photo is from my Soul Stories project, and specifically from the ‘Way Out; Way Home’ installation art (in progress). I ask people who view/participate in this installation to contemplate the meaning of home for them. They then are invited to write or draw the word or phase on a strip of paper, the strips are then added to the blue trap tapestry wallhanging weaving.
  • The connection between sleep and trust and hope was inspired by my current research for the Soul Stories project on the role of narrative in health and healing in the context of homeless. Specifically, this concept comes from anthropologist Hirokazu Miyazaki’s essay/chapter, “Hope in the Gift–Hope in Sleep” in Anthropology and Philosophy: Dialogues in Trust and Hope, edited by Sune Liisberg, Esther Oluffa Pedersen, and Anne Line Dalsgard, (New York: Berghahn Books, 2015).
  • I want to acknowledge the generous support of the University of Washington Simpson Center for the Humanities and the National Endowment for the Humanities for funding support for my Soul Stories public scholarship digital humanities project.

Homelessness Visible: A Photo Essay

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House not for sale. Photo credit: Josephine Ensign, 2015.

The story of homelessness, visible, in my hometown of Seattle, told through photographs and a few accompanying words.

Here, on my daily walk in my neighborhood. Derelict housing, seemingly deserted, unless you know what to look for. Scattered clothing. A tattered backpack.

And this, a most unusual lawn ornament. The 700 metric ton glacial erratic ‘Lone Rock’ now known as the ‘Wedgewood Erratic.’ According to the City of Seattle, it is illegal to climb this rock. But I don’t think it is illegal to camp near it. Hence, this recent living room armchair. And a tent (removed during the day). In the background (the boxy building to the far right), note the supremely ugly new construction ‘single family home’ on the market for a mere $1.4 million dollars. In one of Seattle’s ‘working class’ neighborhoods.

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‘Lone Rock’ and Lone Chair, Seattle. Photo credit: Josephine Ensign, 2016

Yesterday, during a fierce windstorm, there was this homeless encampment in the doorway of an empty store at a busy intersection near my home. A man and a woman were working hard to keep their belongings from blowing away. Note the new (upscale) apartment buildings and the large crane in the hole that will be the new Roosevelt Light Rail Station.

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Homeless in a Seattle Doorway. Photo credit: Josephine Ensign, 2016

And then there are the numerous unofficial ‘tent cities’ and other temporary shelters that all combine to make homelessness in Seattle very, very visible. In follow-up posts I’ll critique the current ‘state of emergency’ of homelessness declared by Seattle Mayor Ed Murray four months ago.

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Man asleep in chair by Seattle city park. Photo credit: Josephine Ensign, 2015

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Homeless encampment on Seattle sidewalk. Photo credit: Josephine Ensign, 2015

Endurance Test

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“No Resilience Here” mixed media, 2015, Josephine Ensign

What helps us—as health care providers, as caregivers, as people, as communities— endure the various traumas and sufferings we’re exposed to indirectly and that we experience ourselves?

Resilience is something that is often cited as an answer to this question. Resilience is a term that has been adapted from engineering to describe the ability of a substance, such as a metal, to return to its previous state after being stressed—the substance is able to bounce back, to return to steady state, to normal. The American Psychological Association definition of resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat.” Resilience is sometimes referred to as ‘good survival.’

Over the past several decades there has been an explosion of research on resilience, mainly focusing on individual risk and protective factors. The main protective factors are, not surprisingly: 1) the formation of a firm, secure attachment to a parent or caretaker figure within the first few years of life; 2) prosocial behaviors and personality traits, such as empathy, a positive attitude, capacity for forgiveness, and ability to ‘play well with others’; and 3) a sense of personal agency, of being able to act, to do something positive both in the midst and the wake of trauma. The main risk factors are, not surprisingly, the opposite of the protective factors.

Most research on resilience has focused on the individual, is Western-centric, and has increasingly become biologically reductionist, narrowing in on the epigenetics of trauma and resilience, finding individuals and entire communities of people with ‘short alleles’ and DNA methylation—genetic markers of increased vulnerability to the adverse effects of trauma. That these are most often individuals and communities already marginalized by poverty and racism and other socially-constructed vulnerabilities, serves to further label and pathologize people and communities. It marks them as damaged goods. As irredeemably, permanently damaged goods. It typically ignores the mounting research evidence indicating that such epigenetic damage is largely reversible and preventable with appropriate life experiences—with access to appropriate life experiences, including effective therapeutic interventions.

Resilience-building interventions include cognitive-behavioral psychotherapy; therapies focused on building the capacity for empathy and forgiveness; narrative storytelling and other meaning-making therapies; and therapies aimed at increasing social support—social support that includes social touch—the human version of primate grooming. Good touch: a handshake, a peck on the cheek, or a hug in greeting; a hand brushing a shoulder in sympathy; sitting close to a stranger on a bus; washing the feet of people who are homeless, people who are rarely touched in a good way.

This all sounds good, but resilience irritates me. The whole saccharine notion that the human body, the human psyche, and even entire communities can be like heated metal—stressed and stretched but not broken—that they can bounce back, return to steady state, and perhaps be stronger and wiser for the experience?  Certainly, I believe that strength-based research and interventions are an important and sizeable improvement over our traditional deficit models so prevalent within health and social services. But resilience has its dark side.

Resilience tends to glorify trauma, and contributes to an addiction to pain and to suffering: What doesn’t kill you makes you stronger. Be the hero of your own life. Cancer saved my life, made me a better person. And Hemingway’s “The world breaks everyone, and afterward, some are strong at the broken places.” It glosses over the fact that trauma and resilience are not equal opportunity affairs, that some people (women, children, people with various disabilities, non-whites, and gender nonconforming people), and some communities (marginalized by homelessness, poverty, racism, and the effects of colonization) are much more likely to be exposed to traumas in the first place, and they have fewer resources to weather and recover from the traumas. It ignores the larger structural inequities, as well as the stigmatizing narratives we place on certain people, communities, and entire impoverished countries. As physician, anthropologist and global health champion Paul Farmer reminds us, “The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise.” (p 288)

Trauma never happens in isolation, even if it is a one-time trauma that occurs to one individual, trauma happens within the context of a particular family, community, cultural, social, and time period. An individual trauma ripples outwards as well as inwards. Suffering from trauma is always a social process; recovering from trauma is always a social process. If suffering is a universal yet unequal human experience, being able to tell and listen to illness and trauma narratives matters. But it doesn’t stop there. Physician, anthropologist, and expert on illness narratives Arthur Kleinman admonishes us that it is the moral and emotional cores of these experiences that matter much more, including the cores of social suffering that especially affect marginalized people.

Kleinman also encourages us to ask the question, What helps us endure? “And I mean by endure withstand, live through, put up with, and suffer. I do not mean the currently fashionable and superficially optimistic idea of ‘resilience’ as denoting a return to robust health and happiness. Those who have struggled in the darkness of their own pain or loss, or that of patients or loved ones, know that these experiences, even when left behind, leave traces that may only be remembered viscerally but shape their lives beyond.” (p 119)

Note: This is an excerpt from a work-in-progress, Soul Stories, a collection of essays on the role of narrative in health and healing.

Sources:

Paul Farmer. ‘On suffering and structural violence: a view from below.’ In: Violence in War and Peace. Edited by Nancy Scheper-Hughes and Philippe Bourgois. (New York)/ Blackwell Publishing (2004). pp 281-289.

Arthur Kleinman. “The art of medicine: how we endure.” The Lancet. January 11, 2014. Vol 383. pp 119-120.

 

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