[This text was originally published in AREA Chicago #15 in December 2015]
Over my many years as a radical left activist, it was never hard to recognize that systemic oppression endangered the health and lives of those who are oppressed. Only once I became a nurse and a nurse practitioner was the true extent of that intimate destruction clear to me; it is totalizing. Regarding health holistically provides a detailed map of oppression’s intersections, especially on the bodies of women, people of color, trans* and queer folks, and, more broadly, the working class. Holistic healing as a healthcare provider depends on identifying these intersections, enabling conditions of self-empowerment, and providing support for positive personal changes, while we all organize to dismantle oppressive forces and create systemic change. And sometimes folks need medicine.
As a registered nurse at a large Federally Qualified Health Center (FQHC) on Chicago’s far west side, I cared for a mostly Black population who were on Public Aid due to poverty or disability. While gunshot wounds were not uncommon, most of my patients came in for prenatal care and chronic illnesses endemic to the west side—diabetes, asthma, hypertension, smoking and poor nutrition—illnesses which correlate rather directly with intergenerational poverty, chronic unemployment, institutionalized racism, environmental racism, and underfunded public schools. Not stemming from any one singly but rather from the overlap and intersections of these simultaneous oppressions, serious and often fatal health problems arise and co-arise, with limited possible response from a healthcare model which works within the confines of capitalism and for-profit care provision.
Federal Qualified Health Centers profess admirable models of care—their not-for-profit status and their mission to “serve the medically underserved” attract workers who want to improve access and outcomes for impoverished communities. But more and more we’re seeing public health clinics closing and FQHCs expanding in their wake, supplanting free clinics with health centers requiring proof-of-income and mandatory assessment of insurance eligibility by virtue of expanded funding from the Affordable Care Act (ACA). FQHCs are the Charter Schools of public health: publically funded private companies with aggressive anti-union management, a low-wage workforce and a devastatingly high turnover rate.
Providers (nurse practitioners, physician’s assistants and physicians) are the income-generators for FQHCs as they perform the direct patient care which is insurance-billable: medical appointments. In order to maximize provider productivity, the more extensive patient education and in-depth follow-up necessary for quality care provision, i.e. non-insurance-billable work which generates no profit, falls on registered nurses and medical assistants. Terming this fragmented assembly line “team-based care,” the millions of dollars of ACA funding that FQHCs compete for is conditionally granted only once this model has been implemented. In other words, community healthcare is being entirely restructured to function in as profitable a manner as possible without federal or administrative acknowledgement of how such a model negatively impacts an organization’s patients or its workers.
Yet the FQHC care model was antithetical to healing even prior to the new ACA funding requirements, crafted to value profit over people by the federal grants on which their existence depends (hence “federally-qualified”). All appointments are 15-minute slots scheduled in four-hour clinic sessions with providers generally working two or three sessions per day. What type of healing is possible for folks mired in systemic oppression, who must wait for two-to-three hours to see an overworked, underpaid provider for a 15-minute appointment? That two-to-three hour wait may be evidence of a provider who is taking more time than they’re allowed to attempt real healing when their hands are tied by insurance coverage (or lack thereof) and patient quotas—the company requirement that every provider see a certain number of patients per clinic session, typically over 20 in an eight-hour day, or their pay is docked proportionally.
The privatization or “charterization” of public health is part of a larger neoliberal task of taking public services—education, healthcare, postal services, transit—and changing their function from necessities freely offered to profits in potentia. Strong public sector unions have been able to fight off the encroachment of the “free market” into our public services, as the Chicago Teacher’s Union skillfully demonstrated in the fall of 2012, though austerity measures too often succeed in taking from us what is rightfully ours. Along with public school teachers, nurses have the strongest, toughest unions in the United States today. It is little wonder that one of the aims of privatization is busting unions and, specifically in public health settings, utilizing the medical hierarchy to divide workers along race, class and gender lines to preempt collective organizing. With an organized workforce fighting for healthy working conditions, increased staffing, lower quotas, longer appointment times and a patient-and-worker-centered model of care, FQHCs might actually live up to their claims of providing quality healthcare to oppressed communities and their supposed belief that healthcare is a human right, not an untapped market.
Individual providers, nurses and support staff can still facilitate healing, despite the system’s attempts to commodify the care we provide. Preventative care is often impossible given our working conditions and increasingly unrealistic demands from administration. Yet, against capitalism’s frenzied odds, we healthcare workers can connect patients to resources to improve access to needed care; educate patients on their bodies and health, as well as their illnesses and environment; listen to them when they share the most intimate details of their lives without hurrying them along to “get to the point;” and disrupt the ingrained provider-patient power imbalance by restoring power and control of their bodies and health back to patients.
Borne of the clergy and the military, nursing has a rich and conflicted history. Famously touting that nurses care for people while doctors treat disease, the nursing model of care professes to value holistic assessment and treatment. The origin of public health nursing was itself a rejection of the dominant norms of capitalist hierarchy to provide holistic care to folks dying of poverty. I came to nursing as a social justice activist wanting to affect meaningful change both through direct care and the creation of new systems. My advanced training to become a nurse practitioner specialized in reproductive health was largely within the nurse-midwifery model of care, a patient-centered approach to pregnancy and labor which asserts that, with the trust and support of providers and community, these experiences can empower parents, and happen without the pathologizing or over-medicalizing invasion of medicine.
There are many traditions and types of midwifery, as birth and its attendants are as old as human history. Unfortunately midwifery in its nursing iteration has often been interpreted in incredibly oppressive ways: willfully ignoring and dismissing queer and trans* identities, idealizing birth over a person’s right to determine their own reproductive future, and judging folks for deviating from the “natural” approach to childbirth and parenting. Classist, racist, misogynist and transphobic ideas can be subtly hidden in the fine fabric of the nurse-midwifery model, despite its face-value justice-minded feminism.
Nurse-midwifery then has near-identical pitfalls to the white feminist movement—from suffrage via the denial of Black humanity, to a pro-choice ideology which assumes an agency not afforded non-white and poor folks, to overt, vitriolic transphobia. Nurse-midwifery must either discard its distorted views of womanhood, agency and bodily autonomy, or new models must be forged and adopted which explicitly address systemic oppressions. As the white feminist movement blundered around, and past making this same decision, intersectional Black feminists posited a different foundation, which can be directly and simply applied to healthcare provision: reproductive justice.
Reproductive justice is a framework which recognizes that the context of our lives—social, economic, political, racial and gender inequities—impacts our ability to make healthy and affirming reproductive choices; it brings together reproductive rights and social justice concepts into an inclusive human rights framework for reproductive freedom. This has a particular salience for women of color in the U.S. whose lives and reproductive futures have been stolen and legislated immeasurably, beginning with the horrific sexualized violence of slavery and the Civil Rights era, enduring both forced pregnancy and childbearing, and involuntary sterilization. This reproductive injustice continues today as white-led movements against Black abortion, denied Medicaid coverage for abortion services, persistent myths about the insufficiency of a Black-female-led household, and the criminalization of pregnancy and motherhood.
Reproductive justice-informed healthcare provision transforms the holistic tenets of nursing and midwifery models of care into revolutionary relationships between providers and communities, facilitating the possibility of true healing and true liberation as we work to tear down that which has wounded and oppressed us. Given the realities of life and health under capitalism, this ideal of provision cannot be fully realized without profound systemic changes from the global working class, that is: all of us, give or take about one-percent. Yet, in the mean time, it is possible to create smaller systems which subvert the dominant model and manage to foster health and hope where there would otherwise be none.
Chicago Women*s Health Center (CWHC) is a radically inclusive feminist health collective which offers primary care, gynecology and trans* health services on a sliding scale to female and trans*-identified folks. Founded in 1975 with the same revolutionary intention as the Jane Abortion Counseling Service (which disbanded in 1973), CWHC was part of the feminist popular health movement of the decade, which peer-educated women on anatomy, contraception and preventative services. CWHC represents what is possible when the medical model’s bad ideas are scrapped; its decent ones refashioned, and healing and empowerment are valued over profit and productivity.
In my role as a nurse practitioner at CWHC, my clients come to me with a variety of concerns, needs and questions—from profound physical illness to preventative inquiry, from complicated medical transitions to respite from previous medical trauma. It is never simple; charting the detailed maps of intersecting oppressions with those who are living them can amount to years-long journeys and may bring us to impassable junctions. But those who expect healing to be simple, to be profitable, to be assembly-line-quick have obviously not ever truly healed anyone or had the opportunity to meaningfully heal themselves.
The care we provide at Chicago Women*s Health Center gives a glimpse into what healthcare settings might be like if capitalism did not determine our access to care and our ability to provide it: safe, peaceful spaces where we can take time and intention to collaborate on what is injurious and how to heal. While creating these spaces is vital to our current and future survival, they alone are not sufficient to heal ourselves. We need to build a mass political movement, which will relentlessly dismantle oppressive systems from multiple angles—through social justice unionism, de-privatizing and wholly subsidizing public services, universal health coverage for everyone without exception, and ultimately removing the most toxic poison to public health: capitalism itself. True healing will require an end to what is killing us, and the creation of a future where our systems enable collective well-being, prevent violence and disease, and protect us from exploitation and oppression.
1, For an in-depth explanation of intersectionality, see: Sharon Smith, “Black Feminism and Intersectionality F,” International Socialist Review 91 (2013-14), http://isreview.org/issue/91/black-feminism-and-intersectionality.
2, Keeanga-Yamahtta Taylor, “Poverty Pulls the Trigger,” Socialist Worker, August 20, 2012, http://socialistworker.org/2012/08/20/poverty-pulls-the-trigger.
3. Some procedures and first-time appointments may be scheduled for 30-minute appointment slots, this luxury undoubtedly the result of provider pushback against near-impossible administrative expectations.
4. Prisons are also being privatized for profit, which merits a separate but related discussion on what constitutes a necessary free public service. For a good starting point, see: Davis, Angela Y. Are Prisons Obsolete? New York: Seven Stories Press, 2003.
5. For an historical examination of healthcare privatization, see: Gaffney, A.W. “The Neoliberal Turn in American Health Care,” Jacobin. April 15, 2014.
6. Semuels, Alana. “The Little Union That Could.” The Atlantic. November 3, 2014. http://www.theatlantic.com/business/archive/2014/11/the-little-union-that-could/382206/
7. Fee, Elizabeth, and Liping Bu. “The Origins of Public Health Nursing: The Henry Street Visiting Nurse Service.” American Journal of Public Health 100, no. 7 (2010): 1206-207.
8. While representative of a certain epoch of feminism which is rife with flaws, Barbara Ehrenreich and Deirdre English’s pamphlet “Witches, Midwives and Nurses: A History of Women Healers” offers one of the most extensive histories of midwifery to date (Old Westbury, New York: Feminist Press, 1973).
9, “What Is RJ.” Sistersong. http://sistersong.net/index.php?option=com_content&view=article&id=141&Itemid=81.
10. Davis, Angela Y. Women, Race & Class. New York, NY: Vintage Books, 1983.
11. McGuire, Danielle L. At the Dark End of the Street: Black Women, Rape, and Resistance- a New History of the Civil Rights Movement from Rosa Parks to the Rise of Black Power. New York, NY: Alfred A. Knopf, 2010.
12. Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York, NY: Pantheon Books, 1997.
13. Kaplan, Laura. The Story of Jane: The Legendary Underground Feminist Abortion Service. New York, NY: Pantheon Books, 1995.