The Single Most Important Course in Nursing School

IMG_7727Now, thirty-two years after graduating from nursing school at the Medical College of Virginia/Virginia Commonwealth University in my hometown of Richmond, Virginia, I can safely say that the single most important course I took in nursing school was not even in nursing. Rather, it was a health humanities/medical ethics course taught in the School of Medicine by a hospital chaplain, Reverend Bob.

Reverend Bob (I forget his last name) focused this course on death and dying and used a small weekly seminar, reading and writing group format. There were approximately ten students, all first or second year medical students except for me. I was in my first year of undergraduate nursing school and struggling to not flunk or drop out. Have I mentioned that I despised nursing school and vowed to never ever teach or go near a nursing school ever again once I graduated?

Now (again), after twenty-one years teaching undergraduate nursing courses here at the University of Washington in Seattle, I can safely say that the Reverend Bob’s health humanities course is the single most influential course on my own teaching. Health humanities matters now more than ever.

According to the International Health Humanities Network based in the UK, this is what ‘health humanities’ is and does:

“Health Humanities draws upon the multiple and expanding fields of enquiry that link health and social care disciplines with the arts and humanities. It aims to encourage innovation and novel cross-disciplinary explorations of how the arts and humanities can inform and transform healthcare, health and well-being. It calls for a much richer body of work that breaks out of limited applications of the arts and humanities to any specific healthcare discipline, as in the medical humanities, which to date has been largely preoccupied with training medical practitioners. As a more inclusive and applied field of activity with a fast-growing international community of researchers, health humanities looks to generate diverse and even radical approaches for creating healthier and more compassionate societies.”

For Reverend Bob’s health humanities/death and dying course, we completed a final portfolio of poems and prose we had written over the semester as reflection on the course content and on our own personal and professional lives. Below, I include photographs of some of the poems (and rough sketches) I included in my final portfolio. Reverend Bob gave me an A-plus for the course. But the grade doesn’t matter to me as much as the lasting solace his course has given me over the many years of my work as a nurse–and as a nurse educator. Thanks Reverend Bob! Thanks to all of the important hospital chaplains out there–no matter what their faith or spiritual persuasion.

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Third Places Rock Democracy

imageHaving recently completed my first cross-country road trip from Seattle to Washington, DC, with frequent bathroom and re-fueling/re-flooding stops in coffee shops and gas station diners in dusty, tumbleweed Western and grits-serving tiny Southern towns, I have a greater appreciation of the role of these ‘third places’ in communities, in civil discourse, and in democracy.

Third places are informal community gathering spaces, separate from the ‘first place’ of home (assuming you have one) and ‘second place’ of worksites. Third place is a term and a concept developed by the urban sociologist Ray Oldenburg. This article in Psychology Today does a decent job of explaining his work on third places.

Being a socially progressive, moderate Democrat-leaning person, I wanted to spend some time immersed in a broad swath of Red States. Especially in Texas, which seems to be one of the Redest states of all. Imagine my surprise, while sitting at a community table at a Starbucks outside of Houston, when I tuned in to the conversation of a group of four middle-aged men. It went something like this:

“We’re all Americans here and we represent a cross-section of our country. I’m a white guy. We’ve got someone who is Jewish, you’re Hispanic, and you’re African-American. And we’re sitting together here talking about things that are important.”

“Yeah, this sure wouldn’t have happened thirty years ago,” said the Hispanic man sitting at the end of the table.

“I don’t understand this,” said the white man. “The Supreme Court justice yesterday equated civil rights of Blacks, Hispanics, and Jews–people who have clearly been discriminated against–with homosexuals and transgender types–who are–what?–less than 1 percent of the U.S. Population. How can that be the same?”

The Hispanic man replied, “If they’re fully realized human beings–they had the surgery or whatever to cut off their penises or whatever it is they do–I’m okay with it. We probably don’t even know there’s a difference. They could be right here or even serving us our coffee of whatever and it don’t matter at all. And everyone needs to use the restroom, so they should be able to do that and not have people harass them over a basic human need.”

All four of the men nodded in agreement and then started to show each other family photos from their phones. I nodded in silent agreement, having ended my enlightening Red State third place eavesdropping experience. And I went to use the mixed gender/any gender Starbucks bathroom.

 

The Roots of Social Justice: It Starts Here

IMG_0335Poet, dramatist, psychotherapist, and anti-oppression trainer Leticia Nieto, who teaches at Saint Martin’s University near Olympia, Washington, uses a photograph of a tree to represent core power, grounding, and personhood, as she puts it “who we really are when all the layers of rigid roles are stripped away.” The photograph she uses is of a leafless tree with gnarled limbs and trunk in the distinct shape of a human body.

I had the good fortune of attending her workshop titled “Social Justice Through Interpersonal Liberation: Strategic Interventions for Anti-Oppression” at Seattle University’s wonderful Search for Meaning Book Festival at the end of February. I’ve subsequently bought and read her book (with co-authors Margot F. Boyer, Liz Goodwin, Garth R. Johnson, and Laurel Collier Smith), Beyond Inclusion, Beyond Empowerment: A Developmental Strategy to Liberate Everyone (Olympia, WA: Cuetzpalin Publishing). Although it has a fairly heady and pie-in-the-sky subtitle, it is an excellent book. I’ve worked my way through the book, revisited my notes from her workshop, and thought about what it all means for me. I’ve also spent time searching for my own photograph of a tree that represents my own life, grounding, personhood. I considered using a photo I took in New Zealand of the grand Tane Mahuta, an old growth giant kauri tree on the North Island that is upwards of 2,500 years old. That was when I was feeling a bit grandiose. As much as I love that tree and New Zealand, those are not my roots.

My roots, my ‘personhood’ tree is this old Black Oak tree still growing in the leafy green woods of Camp Hanover, my childhood home. This particular oak tree is growing beside on old family graveyard–a family I am not related to as far as I know. The roots of this tree are in complex territory, territory I am still wrestling with in terms of my own social justice and anti-oppression work. Here are a few excerpts from the chapter “First Families” in my forthcoming medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (Berkeley: She Writes Press, August 2016)–excerpts that describe some of this territory:

“The land I grew up on near Cold Harbor [Virginia] had been the site of the bloodiest battles in the Civil War. The two battles were two years apart; soldiers on both sides in the last battle unearthed decomposing bodies from the previous battle as they dug trenches. Our land was strewn with Civil War bullets, musket balls, deep earthworks, and mounded graves. Long before, the Pamunkey Indians had scattered the land with white quartz arrowheads.(…) [There was] as family burial site. leaf-strewn mounds of earth bumped together in a line like the cedar logs on the corduroy road. The site was on a bluff overlooking a ravine cascading down to a small stream. Most of the graves had carved gray headstones: Robert Anderson born March 10, 1792, died July 26, 1853: William Nelson Anderson born February 16, 1837, died May 15, 1851; and, Nancy Peasley Anderson born April 18, 1833, died July 15, 1834. Nancy’s grave was short, but there was an even shorter grave next to it of another Nancy, “infant granddaughter” Nancy Julia Elizabeth with no dates given. A few feet away were six or so unmarked graves, which my mother said were those of Negro slaves. These couldn’t have been content, but I didn’t see their ghosts back then. It was as if they had never existed.”

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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