Health Care as Political Weapon

Version 2Access to affordable, quality, basic health care is a basic human right. Basic, as in fundamental and essential. In a civil society, in a democracy, health care should not be used as a political weapon—as it is being used by the current U.S. government administration. Using health care as a political weapon is sick. That it is being used as a weapon by powerful, affluent (mostly men) with the best health care and most comprehensive health insurance in the country—against those of our society who have the least power and resources, is despicable.

Repealing the ACA, which all health policy experts agree has had far-reaching positive effects on our health care system and on millions of people’s access to care, is senseless and mean-spirited.

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For a brilliant critique of the current heartless rhetoric of the leaders of the ACA dismantling, please read Nicholas Kristof’s NYT op-ed piece, “And Jesus Said Unto Paul of Ryan…” (3-16-17).

The Role of Trauma-informed Care

IMG_1055Time to revisit and review trauma. Trauma-informed care is health care provided within the framework of an understanding of the various neurocognitive, psychological, physiological, and social effects of trauma on individuals. People who are homeless have particularly high rates of trauma—both before and during their experience of homelessness. And, of course, homelessness itself is a type of trauma, a type of deep illness, as sociologist Arthur Frank refers to an illness that casts a shadow over your life.

Trauma is an event that is life threatening or “self” threatening. Serious accidents and medical mishaps. Drug and alcohol addictions. Natural and manmade disasters. Wars. Rape. Intimate partner violence. Childhood neglect, physical, and sexual abuse. Complex trauma is trauma that occurs within key caretaker relationships and that is pervasive and enduring. Complex trauma is, well, more complex to live with and to treat.

We use the phrase scared speechless to describe fear that overwhelms and suppresses the speech and language area of our brain while we’re in the midst of a traumatic event. As Bessel Van Der Kolk, a physician and expert on trauma puts it, “All trauma is preverbal.” (p 43) Trauma bypasses these higher order areas of the brain and goes straight to the more primitive fight and flight fear area—the amygdala, two almond-shaped areas deep inside our brains in the primitive limbic system. Trauma is not stored as a storied memory with a clear-cut beginning, middle, and end, but rather as fragments of experience, images, smells, sounds, and other bodily sensations. That is why people who have survived a significant traumatic event—even years and decades after the trauma is over—struggle to tell the story of what happened. Yet their bodies bear witness to the event through terrors, flashbacks, numbing, and stress-mediated physical problems like migraines and auto-immune diseases—diseases in which the body turns on itself, as if in slow suicide. If the trauma happened to the person as a child before the firm development of a sense of self, that person’s memories of the event can remain visceral and largely inaccessible to verbal processing.

Van der Kolk states, “Almost every brain-imaging study of trauma patients finds abnormal activation of the insula. This part of the brain integrates and interprets the input from the internal organs—including our muscles, joints, and balance (proprioceptive) system—to generate the sense of being embodied.” (p 249) He points out that the flood of activating neurochemicals from the fight or flight response to trauma effectively cuts people off from the real origin of their bodily sensations; the fight or flight flood numbs people, and is the reason for dissociation and out-of-body experiences many trauma patients deal with. Van der Kolk goes on to declare, “In other words trauma makes people feel like some body else, or like no body. In order to overcome trauma, you need help to get back in touch with your body and your Self.” (p 249)

Art, music, and dance are often used as treatments for trauma patients because these expressive modalities do not depend on language. They do not depend on—indeed, they are better off without—the use of our rational minds both to create and to experience. As psychiatrist Laurence J. Kirmayer writes, “And if the text stands for a hard-won rational order, imposed on thought through the careful composition of writing, the body provides a structure to thought that is, in part, extra-rational and disorderly. This extra-rational dimension to thought carries important information about emotional, aesthetic, and moral value.” (pp. 324-325)

In the late 1990s, in a Seattle area community health clinic where I worked as a nurse practitioner, many of my patients were Bosnian and Ukrainian refugees. One of my more heart-wrenching patients was a 4-year old Bosnian girl whose teeth were rotted to the gum line because her mother had given her a sugar-soaked rag to suck to keep her silent as they tried to escape the civil war. The language interpreter told me that the child’s older brother had ben killed, and that her mother had been raped. I referred the child to our children’s hospital where they surgically removed all her baby teeth and then fitted her with child dentures until her adult teeth appeared. I was hoping to refer the mother for talk therapy to deal with her traumas, but soon realized it was best to refer her for massage therapy with a trauma-informed female therapist. I worked with our clinic social worker to petition the patient’s health insurance (which happened to be the state Medicaid office) to pay for this—what we typically consider slightly frivolous and self-indulgent treatment. Medicaid paid for the massage therapy and it seemed to lighten her depression. This wasn’t art, music, or dance therapy, but it was body-based therapy.

The body remembers. Maddy Coy, a UK-based researcher who works with survivors of prostitution, maintains that especially for women who experienced childhood sexual abuse (a startlingly high percentage of prostitutes worldwide), the use of appropriate body work such as yoga and massage is oftentimes crucial for recovery. Body work helps traumatized people reestablish a focus on what the body can do instead of what is done to the body.

Early in my career as a nurse I worked for a year in a safe house emergency shelter for women who were escaping intimate partner violence. Before my work there I did not understand the concept of trauma mastery and how this played out in the lives of women caught up in the cycle of abuse. I sided with the common misperception that the reason so many women return to their abusive partners is because they are psychologically damaged and weak. There is the not insignificant role of addiction to the thrill of trauma and danger—to the effects of the activating yet numbing fight or flight neurochemicals—which can bring at least temporary relief to the bouts of fatiguing depression that often accompany trauma. Then there is the unconscious attempt to return to the site of previous trauma to get it right this time, to do what we wish we could have done the first time, to master our trauma.

As social worker Laura van Dernoot Lipsky points out, these unconscious attempts to master our traumas often backfire and simply reinforce our old traumas. Lipsky goes on to say that many of us in health care and other helping professions often are using our work as a type of trauma mastery, and that by doing so we may set expectations for ourselves and others that are “untenable and destructive.” She advocates ongoing efforts aimed at self-discovery and self-empathy, and points to the many positive examples of “people who have been effective in repairing the world while still in the process of repairing their own hearts.“ (p 159) Eve Ensler and her personal, combined with world repair, work that she describes in her powerful book In the Body of the World, is one of my personal favorite role models for this sort of balanced approach.

Ally is a Verb

IMG_1807.jpg“I’m tired of ally being used as just a noun—we need to remember that ally is a verb.” This was one of the more powerful statements made this past week by Roxane Gay, author of Bad Feminist, at her Seattle Arts and Lectures talk at Town Hall Seattle. To me, this is an important reminder to speak up and act up to address and redress the despicable hate speech and violence currently bubbling up from the sewers and cesspools of our country—and directed toward anyone who is not white/straight/male/American citizen/so-called conservative Christian.

We are living in dangerous times. Documented hate crimes are occurring daily, hourly, across our country and so much so that hate crime watch groups like the Southern Poverty Law Center and the ACLU are working hard to keep up with all of them. The Southern Poverty Law Center has an interactive Hate Map where you can look up the location of a currently active hate group (of the over 1,600)  in the U.S. that they are currently tracking. Having been born and raised in rural Virginia near the former capital of the Confederacy, Richmond—and on the South’s first racially-integrated children’s summer camp—and, oh yes, being a classmate of  (and receiving death threats from) the Grand Dragon of the Loyal White Knights of the KKK—I am not at all surprised to see the number of KKK and White Supremacist groups currently alive (and unwell and festering) in my home state of Virginia. I am, however, dismayed and discouraged to see that in my adopted state of Washington we currently have six white nationalist/skinhead/neo-Nazi groups, as well as three anti-islamic groups. Although I am not surprised even by that, given the fact that starting on Trump’s inauguration day last month, flyers (including razor blades affixed to the backs of them) from white supremacist groups, began appearing on the walls of classrooms—and even the hospital—of the University of Washington in Seattle where I teach.

Despicable. Cowardly. Violent and hate-filled vitriol that has absolutely no place in our society. This is not free speech; this is hate speech. There are no Constitutional or moral or religious or anything else protections for such actions, such words.

Roxane Gay ended her talk with this statement: “I have to believe there is grace beyond the disgrace.” Ally is a verb. Act now and weigh in on the side of grace.

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An additional and new resource for reporting of hate and bias crimes is Propublica’s site Documenting Hate. Use it.

Body, Soul, Survival

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University of Washington, Seattle. Photo credit: Josephine Ensign/2017

“Health is politics by other means,” asserts Columbia University professor of sociology Alondra Nelson in her fascinating book Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination (Minneapolis: University of Minnesota Press, 2011). Nelson acknowledges that her statement is inspired by French philosopher and scientist Bruno Latour’s assertion that science is politics by other means. For anyone who ever doubted either of these assertions—or thought they were alternative facts—you must live in the Land of Narnia.

Before reading Nelson’s book I knew that Black Panther Party for Self Defense had created community-based primary care health clinics in many major U.S. urban areas in the late 1960s/early 1970s. But I did not understand the true breadth of their healthcare activism. I worked as a nurse practitioner for about six years at Seattle’s Carolyn Downs Family Medical Clinic , originally formed in 1968 as a Black Panther clinic. It is located in the Central District of Seattle, a traditionally black neighborhood that is now significantly gentrifying. It is named after an early Black Panther community organizer, Carolyn Downs, who died at an early age of breast cancer—something that most likely could have been detected and more effectively treated if she had had better access to the primary care now provided by the clinic she helped develop. A highlight for me of working at Carolyn Downs Clinic was being able to care for one of Carolyn’s granddaughters.

The Black Panther Party for Self Defense was formed in Oakland in 1966 as a survival tactic “to afford protection for poor blacks from police brutality and to offer varied other services to these same communities.” (pp. 5-6) These services included the establishment of no-cost community-based primary care clinics, sickle-cell and blood pressure screenings, free breakfast programs for children, and after-school and summer tutoring programs. They also formed teams of patient advocates who accompanied their patients to hospitals or specialty care, heralding our current system of patient navigators. The Black Panthers were also instrumental in challenging the formation of the Center for the Study and Reduction of Violence at UCLA, a research center backed by the California governor Ronald Reagan, and which promised to find the origins of violence. It was to be headed by psychiatrist Louis Jolyon West, whose previous research included experiments with sleep deprivation, LSD, and correlating the era’s student activism with antisocial behavior. (pp. 153-154) The Black Panthers contended that aggression for people within marginalized communities was a legitimate response to oppression. They, along with many other activists, were successful in blocking funding for this center.

The American Journal of Public Health (AJPH) dedicated its entire October 2016 special edition issue to the public health work and legacies of the Black Panther Party. As physician and AJPH editor-in-chief Alfredo Morabia writes:

“Now that a new generation is carrying on the ideals of the health activists of the 1960s, it is time to revisit this history, understand the strengths and weaknesses of the BPP public health initiatives, and have a frank debate about what really happened. The stakes are huge for an emerging generation unwilling to accept that certain lives matter less than others, and that, as the recent massive lead contamination of the Flint, Michigan, water system shows, many poor (and Black) communities still remain defenseless against such overtly aggressive assaults to their health in a context in which, as Angus Deaton puts it, the infamous one percent is not only richer but much healthier.”

Read more in this AJPH special issue: http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303405

Additional resources:

The Seattle Black Panther Party History and Memory Project, part of the University of Washington’s Seattle’s Civil Rights and Labor History Project, led by UW professor of history James Gregory—contains videotaped oral histories, historical photographs and news coverage and more.

 

Love and Sex in the Time of Misogyny

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“Woman in Love” stainless steel, 1983, Bob Haozous at the Heard Museum, Phoenix, Arizona. Photo credit: Josephine Ensign/2016

Prostitution is commercial sexual exploitation and no, I’m not throwing women under the bus by stating this, and yes, I am a feminist. Prostitution is not a victimless crime. Prostitution is a public health issue. Prostitution is a significant part of continued and even accelerated violence against women and children. Amnesty International‘s prostitution policy, which was enacted on May 26, 2016, frames prostitution as sex work, pimps as legitimate sex business operators, and johns as deserving customers. Did Amnesty International sell its human rights soul to the highly lucrative and heavily male-dominated sex industry?

Consider this: “The commercial sex industry is sustained through violence and exploitation. Prostituted people live with the daily threat of violence. Traffickers and pimps are not the only abusers—buyers cause tremendous harm through the repeated sexual use of women and children and other physical and psychological violence. Sex buying exploits vulnerable people and hurts our communities.” (source citations at Ending Exploitation.)  The vast majority of women and children who are prostituted come from poor and marginalized communities and have histories of childhood sexual abuse. The typical age of entry into prostitution is 12-15 years of age and upwards of 90% of all prostituted women and children want to leave “the life.” And in countries that legalize/decriminalize/regulate prostitution, the demand increases as does the number of women and children (typically, again, from impoverished and marginalized communities) trafficked into prostitution.

And consider this innovative Seattle-based program on men’s accountability (and misogyny and perpetuation of the patriarchy): The Buyer Beware partnership to end commercial sexual exploitation, coordinated by the King County Prosecuting Attorney’s Office and the Organization for Prostitution Survivors (OPS).  The Buyer Beware model emphasizes prosecuting (and educating) sex buyers and connecting prostituted women and children to services. The goal of the program is to reduce demand for commercial sex, thereby decreasing harm to prostituted persons, reducing self-destructive (toxic masculinity) behaviors of buyers, and curbing sex trafficking in our region. This is a highly enlightened approach and one that our health system—including public health—should support. For instance, standard screening questions on sexual health for health care providers to use with patients can include ones pertinent to sexual exploitation and the buying of sex, along with appropriate referrals for assistance.

In the Seattle area we have YouthCare’s Bridge Program for prostituted teens, the OPS programs for adult women seeking to exit commercial sex exploitation, and the OPS men’s accountability program “Stopping Sexual Exploitation: A Program for Men.” There is a recent and fascinating GQ article “Can we ‘cure’ the men who pay for sex?” about this program by Brooke Jarvis (February 2, 2017). In the article, Jarvis avoids straying into the current political climate as it relates to the fueling of toxic masculinity and violence against women, but she does write this tagline: “Inside a two-month program that aims to end prostitution—and help dismantle the patriarchy—by rehabilitating the men who perpetuate it.” It should be abundantly clear that this is a lofty—and essential—goal for all of us to be working towards.

Beyond Endurance Test

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Untitled, oil on canvas. Erika Kahn. Photo credit: Josephine Ensign/2017.

These dark, uncertain times demand our full attention, compassion, and capacity to endure beyond what we previously thought we could endure. And by this I do not mean passive suffering or some sick, masochistic hair-shirt sort of endurance. Nor do I mean resilience, the saccharine notion that the human body, the human psyche, and even entire communities (or countries) 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?

Paul Farmer, physician and global health expert, reminds us that,  “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.” (1)

Trauma never happens in isolation. 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.

Resilience, either from an individual or a community (or country as we are now facing), even if it were possible, would it be desirable? If most traumas, most disasters, are at least partially caused by and certainly compounded by social (in)justice issues, do we want to return to normal, to the status quo after our worlds, our bodies, our communities have been shaken to the foundations, have been seared by fire, have been permanently altered and scarred? Skirting close to the danger of glorifying trauma, of feeding an addiction to the pain and suffering so overly abundant in our world, is the recognition that individual and community healing “means repair but it also means transformation—transformation to a different moral state.” (2) And it means enduring, going on, doing what we can individually and collectively to transform the world for the better.

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Adapted from my book manuscript for Soul Stories: Voices from the Margins.

Sources for quotes:

  1. 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. Quote is from p. 288.

 

  1. Veena Das and Arthur Kleinman, “Introduction,” in Remaking a World: Violence, Social Suffering, and Recovery, ed., Veena Das, Arthur Kleinman, Margaret Lock, Mamphela Ramphele, and Pamela Reynolds (Berkeley: University of California Press, 2001), 23. (Quote is from “Introduction” pp. 1-30. Quote is from p. 23)

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

Past the First Step

img_1288-2Reasons for hope abounded yesterday, here in Seattle and in cities and towns around the world—and even on a ship in Antarctica. This is why I march(ed) and this is why I continue to march today. We can and we must do this together: make America think (and resist tyranny) again. Think about this statement in de Tocqueville’s Democracy in America: “And what I find most repulsive in America is not the extreme freedom that prevails there but the shortage of any guarantee against tyranny.” (From the chapter “Tyranny of the Majority, p. 294.)

Participating in the Women’s March, either in person or in spirit, is the first step towards a safer, more socially just society. It does not end there. If you live and breathe in the United States and if you care about women’s rights, children’s rights, immigrant’s rights, LGBTQ rights, healthcare rights, environmental rights—you name it rights—it is time to take the next vitally important steps and get involved, get informed, get politically active in whatever ways you feel comfortable. And for everyone’s sakes, in ways that make you uncomfortable. Here is a link to the Women’s March on Washington’s 10 Actions in 100 Days. They make it ridiculously easy for you and your friends and family to take those next steps.

And please remember to pace yourself as you begin taking those steps. We don’t need people collapsing on the sidelines. I like this simple framework for sustained advocacy from writer-activist Mikki Halpin in her post titled “Do Something. But You Can’t Do Everything” (1-24-17):

“Here is how I would suggest you take a step back and think about how you are going to be a change maker now and in the years to come.

Think about all of the things swirling around you, all the opportunities you have to do things and act on your values and choose these three things: 

One thing to be a leader on
One thing to be a follower on
One thing to make a habit of”

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