By any means necessary…

“Wash me thoroughly from my iniquity, and cleanse me from my sin.”  – Psalm 51:2 

I was at Whole Foods (I know I know…) the other day using the restroom.  Someone in the stall next to me was clearly having a bowel movement.  No big deal, right?  People do these things.  Predictably, the toilet flushed and the stall door opened.  But then, the bathroom door opened.  The silence of the sink faucet was deafening.  I tried to rationalize.  “Someone else must have come into the restroom.  Who would leave without washing their hands?”  I turned to find the restroom frighteningly empty.  My mind started to race.  “Oh my God!  Have they done all their shopping?  Shit, I need kale.  What if they touch the kale? What if I check out using the same check out stand they did?”  Needless to say, I left the store carrying prepackaged kale and a bottle of (organic French lavender) hand sanitizer.

This, unfortunately, is not a rare occurrence.  Studies have shown that rates of hand washing are alarmingly low, 77% in men and 93% in women.  Given that so many diseases are spread through the fecal-oral route, this is something to think critically about how to improve.

As previously mentioned, the bathroom was completely empty (aside from me in a stall) when this person left.  They didn’t have to look at anyone, or really be accountable in any way to the fact that they walked into a store full of things people put in their mouths with E. coli (AKA poop) covered hands.  What if they had?  What if I had been washing my hands when they left the bathroom stall?  Research suggests that this may have changed the outcome.  While I don’t like to admit it, people are sheep.  We like to conform to what is expected of us.  This is true when it comes to hand washing as well.  When people are observed, they are more likely to wash their hands than if they are alone.  That being said, we don’t spend the majority of our days in the bathroom.  Public restrooms generally aren’t as crowded as the areas they service (thank God).  So we either need to find ways to get more people in bathrooms to increase peer pressure, or get people to wash their hands in public.  Given that many feel more comfortable in single occupancy restrooms, or unisex restrooms, getting more people into bathrooms isn’t a solution.

One beautifully simple way to do this is to remove sinks from bathrooms entirely and put them outside.  One grocery store has done just that (whether it was intentional or not I don’t know).  Like many grocery stores, this store has a seating area where people can sit to drink coffee, or eat lunch.  Right next to this area, and within full view of the large seating area, are the restrooms.  There is nothing special about them.  What is interesting is that the sink is outside the restroom, in full view of everyone in the store.  In order to leave the restroom without washing your hands, you have to walk by dozens of judging eyes.  While I would like to think people would wash their hands because it is the right thing to do, clearly they don’t.  If the only way we can increase hand washing rates is through guilt and shame, so be it.  Clean hands by any means necessary.  Good work unnamed grocery store.  I would eat your produce any day.

Playing Doctor… Abroad!

“When I give food to the poor, they call me a saint. When I ask why the poor have no food, they call me a communist.”  – Hélder Câmara

As summer comes to a close and school resumes, thousands of college students are returning from trips to developing countries where they have been playing doctor or nurse for a few short weeks (DON’T PANIC! You didn’t miss anything! Go to their blogs and Facebook posts for a recap of their trip).  These trips, termed short-term medical missions, generally involve premed or nursing students travelling to impoverished areas and providing medical care.  Frequently, these students lack the appropriate training and perform tasks that would never be permitted in their country of origin, such as pap smears and injections.  (Caveat: Medicine has a very recent history of having medical students “practice” skills such as pelvic exams on anesthetized women without their consent even in the United States).  Fortunately (for the wannabe doctors and nurses… sentences referring to the impoverished recipients “served” generally will start with “unfortunately”), groups that market these short-term medical missions help participants skate around these blatant ethical dilemmas with rhetoric such as, “With small health clinics and understaffed hospitals serving low-income communities, volunteers support the over-worked staff, adding to their efficiency and allowing more people in need to be served.”  Participants are made to think, “Sure, I may not be adequately trained, I may not speak the language, I may only be there for 2 weeks… but it is better than nothing!”  (It isn’t).

All these ethical landmines aside, many organizations play to the white savior complex and are marketed to and perceived by participants to be humanitarian or “service” work.  “Volunteers” are told, “As an international volunteer you can effect positive change for people around the world.”  Aside from the fact that research has shown that this is not true, this is an obscenely oversimplified view that discourages rather than encourages critical thinking (possibly a trait we should try and nurture in future health care workers?).  Rather than asking, “What structural forces are at work leading to such poorly funded health systems and abject poverty?  Why are people drinking dirty water when they know there is a cholera outbreak?” these programs sell a prepackaged altruistic identity and make participants think, “Gee, let’s go help those poor, helpless Africans… and go on a safari!”  This downstream approach is unsurprising given the health care system in the United States profits from treating rather than preventing disease.

As a testament to the fact that health services are severely underfunded, one organization states on its website that there are only 74 doctors per 100,000 people in South Africa.  However, they conveniently fail to mention that austerity measures imposed on South Africa by the DC-based IMF and World Bank force spending cuts to health services.  This form of coercion goes under the benign name of “structural adjustment programs” (maybe if we sent aspiring chiropractors to implement spinal adjustment programs we wouldn’t have this problem).

It also conveniently leaves out the unfortunate (I told you) fact that Sub-Saharan African countries have lost over 2 billion dollars spent on training doctors.  Where do they go?  Fortunately (again, for the first world) mostly Britain and the US.  These countries have saved an estimated 2.7 billion dollars (Britain) and 846 million dollars (US) by poaching doctors trained in Sub-Saharan Africa (I don’t mean to sell us short; we steal doctors from other countries as well… 1:4 doctors in the United States was trained overseas).

Other medical mission trip organizations discuss the increase in cholera and lack of clean water in South Africa, but fail to mention the role of water privatization (again, forced by the IMF and World Bank) (Patrick Bond has a great article on this in the book “Sickness and Wealth”).  The list of oversimplifications and contradictions is endless.

       “But what am I supposed to do this summer if not practice (non-existent) medical skills on impoverished individuals or burden communities with too few resources as a means of promoting health?”

As mentioned earlier, policies coming from developed nations are largely responsible for problems in the developing world.  Whether it be global warming leading to droughts and famine in Africa or structural adjustment programs that have, according to the World Health Organization, “slowed down improvements in, or worsened, the health status of people in countries implementing them,” we need to look in the mirror when it comes to culpability for the poor health indicators of many developing nations.  For this reason, the best place to promote health is not travelling abroad to the figurative front lines where the casualties of neoliberalism build, but rather behind enemy lines where political and economic powers undermine health through policy.  Nurses are taking the lead in recognizing the relationship between policy and health and have started protesting institutions like NATO and Wall Street.  Another form of patient advocacy one nurse notes.

I won’t pretend to have all the answers. After all, changing the world is no easy task.  Creating healthier populations is a brave thing to fight for.  Odds are though, if we continue this struggle in a way that isn’t upsetting people and causing conflict, we are treating symptoms of a larger problem at best, and reinforcing the current systems that undermine health at worst.  The chains of oppression will not break without tension.  You don’t need to travel to the other side of the world to make a difference.  But if you do, go abroad to fight for the health of those living in the developing world, stand beside them in solidarity, pick up the chains, and pull.

Costco & I-1183: Subverting democracy and undermining public health

Health – what my friends are always drinking to before they fall down.  -Phyllis Diller

With prices up between 10 and 30 percent, it appears that the privatization of liquor in Washington didn’t work out for consumers.  Fortunately, as a nurse, advocating for cheap liquor isn’t in my job description.  However, advocating for the health of individuals and communities is.  For this reason, I-1183 has been absolutely maddening.  There is already consensus within public health circles that increases in the density of liquor outlets lead to increases in alcohol consumption, alcohol related deaths, and assaults.  Despite my awareness of this, I sometimes get naively optimistic and think that we are more civilized than to allow something like increased access to liquor change our drinking patterns… and then I visit the University District Safeway at midnight the first day liquor was available and am abruptly brought back to reality.  I walked into the store and found a crowd of college students (most already intoxicated) in front of nearly empty shelves.  According to the security guard, the shelves had already been restocked… twice… that evening.  Watching this Kirkland Signature™ brand legislation exacerbate an already man-made epidemic has been facepalmingly demoralizing.  I want to tell the state Supreme Court Justices that ruled in favor of the initiative, “I can treat alcohol poisoning.  I can do post-liver transplant care.  But as long as you keep perpetuating the conditions that lead to binge drinking and alcohol related liver failure, I’m just putting on very expensive band-aids at taxpayer expense.”  Policies like I-1183 make me feel like Sisyphus in scrubs.

A few days after the law went into effect, I was excited by what I read in the paper.  It turns out that most voters don’t have an elementary understanding of economics (SURPRISE!) and didn’t anticipate the extra fees on wholesalers and retailers being passed onto them.  In simpler terms, the fees drive up prices.  The sharp price hikes have been met by consumers with shock and indignation.  I did a (very unscientific) Twitter search to see what people were saying about the new law after it went into effect. @ChicoOffTheWall snarkily said, “Cheap liquor is the new expensive liquor.” @Igotjewels was more frank, “Selling liquor in the grocery store isn’t even tight, it’s fucking expensive.”  It was this reaction that got me thinking, “Hey, maybe I-1183 isn’t quite as bad as I thought.”  After all, one of the most effective strategies to reduce both consumption of alcohol and the associated harm is taxation.

Unfortunately, as there aren’t any examples where access to liquor and prices simultaneously increased, it is impossible to know the net effect this policy will have.  However, seeing consumer awareness of the higher prices leaves me relatively less discouraged.  Perhaps the negative health impacts associated with increased access will be mitigated by the increased costs.  I am particularly optimistic given that the drinking patterns of youth are most heavily influenced by price.  Regrettably, there won’t be any objective measure to see if this is the case for the next couple years.  Until then we can only wait and hope for the best.

So what can we learn from this?  @xlandsharkx hit the nail on the head by saying the day before I-1183 was enacted, “Go buy your liquor today cause it’ll be 30% more expensive tomorrow. Hey, as long as Costco’s fuckin happy then whatevs right?”  After spending $22 million dollars to effectively purchase this legislation, why wouldn’t they be?

Thanks to Washington State’s “have it your way” system for corporations and wealthy special interests (i.e., the initiative process), anyone or any group with money can put virtually anything (constitutional or not) on the ballot.  How?  By renting mercenaries to gather the needed signatures.  After that, all that is needed is a volley of misleading advertisements and voilà!  You have just dismantled the state’s liquor system.  I suppose one could (misguidedly) argue that corporate interests and the health of the community are not always mutually exclusive.  However, a look at recent initiatives passed shows that the initiative process is being hijacked by corporate interests at the expense of the public’s health.  The American Beverage Association (a front group for Coke and Pepsi) donated 99.99% of the $16.5 million spent to repeal a temporary tax on soda, candy, and bottled water (you know, the essentials).  Opposition groups were only able to raise a pathetic $390,000.  While such taxes are regressive, they are also an effective way to decrease consumption of these products.  As these products contribute to obesity, diabetes, and the destruction of the environment, we should be enacting policies geared towards encouraging less consumption.  That Coke can repeal what may have been an effective public health measure for the sake of their bottom line is a sign that government is organized to put the interests of corporations over the interests of the people.

Another example of the failure of the initiative process would be I-1098, a piece of legislation proposed by William Gates Sr.  It was an initiative that would have directed funds specifically to education and health services through the enactment of an income tax on individuals making over $200,000 a year and married couples or domestic partners making over $400,000.  It was killed by massive donations from (ironically) Microsoft CEO Steve Ballmer ($325,000) and Amazon CEO Jeff Bezos ($100,000), among others.  Yes Virginia, Amazon CEO/paranoid libertarian Jeff Bezos drops on one state initiative what a new teacher makes over 3 years in order to prevent the government from having the ability to pay teachers.  As long as corporations and wealthy individuals have the ability to write legislation specific to their interests and kill legislation contrary to their interests, the health of the community will be collateral damage.

The end result of I-1183?  Consumers feel cheated as they are paying more for liquor; public safety and the health of the community are jeopardized; craft distilleries are going under… But it all seemed to work out for Costco.  So let’s raise a pint (of Kirkland Signature vodka) to Costco, and pray that their plan to privatize liquor in Idaho is(nt) successful.  Oh, and for those that lose a loved one on the not-so-off chance that there are increased rates of death attributable to this legislation, Costco is having a great special on caskets… and 5 liter bottles of vodka to help you drown your sorrows as you cope with their senseless death.