Nurses at the Margins

January-February 2016


When I graduated from nursing school, some of my fellow classmates offered to buy me a gun to equip me for my first nursing position. Just across the river from my home in Missouri, the city of East St. Louis, Illinois, was considered dangerous territory by most. But I saw things differently. Several months into my job, as I drove one day across the Mississippi River, I remember thinking what an honor it was to work there. This is exactly the kind of place Jesus would be born in today, I thought as I circled the off ramp toward the health department. No one ever thought any good could come out of Nazareth either, I remembered.

Nursing is rooted in service to those who are sick and poor, the marginalized but resilient, the lonely and oppressed. Many had gone before me (usually women) to do this very thing: heal the sick in forgotten places and work for justice in their neighborhoods. Armed with a signed copy of Veneta Masson's memoir, Ninth Street Notebook: Voice of a Nurse in the City, the support of a faculty mentor, and my fresh nursing education, I went to serve in exactly the kind of place I longed to be. I was naive, maybe, but ready. Ten years later, I still believe nurses are called to prioritize their care to those who don't have easy access to health and health care. I am taking this opportunity to share what I have learned on this trying but fulfilling vocational journey.

I've always been drawn to people on the margins. I fit better there. So when I decided to be a nurse, of course I was drawn to apply those skills to people whose health was at the margins and who often are left out of access to health care. I've had a lifelong curiosity about getting to the root of issues in order to drive out the causes of illness or brokenness. In high school I travelled to developing countries on various service trips, which opened my eyes to the beauty that exists in human variance and the commonalities we have despite our differences. By the time I was in college, the disparities the poor faced were more than interesting to me — they appalled me and called me to action. Hence, my path into public health nursing.

My position in the East St. Louis public health department was part of a program called Nurses for America (NFA). Modeled on AmeriCorps' Teach for America program, NFA placed bachelor's degree-prepared nurses in settings that struggled to attract them. Before my group's 18 new nurses were installed in their individual positions, we had two weeks of training by and among nurses similarly passionate about serving marginalized people. Veneta Masson came to describe her desperate, as well as deeply satisfying, moments while nursing in a Washington, D.C. free clinic. I remember learning that when we talk of at-risk or vulnerable populations, we always need to couple those terms with "resilient," because these are individuals and groups who have risen above some of the most grueling situations, far beyond what many middle- and upper-class people can imagine.

I learned other new things: Little did I know that nursing started off as a profession created for those no one else cared about, how nurses themselves often were on the margins. My heart was even more drawn to the profession when I learned that the foundations of formal nursing are associated with the Christian tradition. Tenets such as a preferential option for the poor, belief in the dignity of each person and working for the common good reflect God's character and are the basis from which the profession has grown. It is logical then that our practice of alleviating the suffering of individuals and populations leads us to care for the people society has most neglected. Although the appearance of those on the margins may change over time, the opportunity to care for them will never end until we dig out the reasons behind the disparities in our policies, our organizations and even in our own hearts.

As a public health nurse working with families whose children have been diagnosed with lead poisoning, I found the toughest battles were not with the families, but with systems, circumstances and policies that disable people's ability to be, stay or become healthy. The great majority of lead poisoning cases come from the paint in old houses rented out by slumlords allowed to disregard building codes and standards of repair.

There were two worlds I came to recognize. The one I experienced and assumed worked for everyone else was where neighborhoods were basically safe, people were basically law-abiding, and jobs and health insurance were within grasp. My travels in high school and college showed me poverty and unsafe conditions, but it was not until I worked day in and day out with some of our patients in East St. Louis that I began to understand the world didn't work for everyone like it did for me. Nor did the way my world worked have anything to do with what I had done or earned.

I realized the way housing, education and even health care were set up is correlated to current segregation, economics and health disparities. Laws and regulations were enforced for some and not for others, depending on skin color, gender, appearance, money, education, connections. Grocery stores in certain neighborhoods would disappear, leaving behind little corner stores with limited fresh and healthy food options.

It was obvious that the most up-to-date science and best care often were kept at arm's length from my patients. I've heard it takes 17 years for research to get into practice. That dissemination seems to double in places like East St. Louis. I saw project proposals get tossed out that might have indicated some county responsibility in the slumlord business, because it was an election year. Logic follows that if some are left out or denied access to certain necessities of life, they will create another way of life just to survive. This is the other world that I came to know as I worked as a nurse in East St. Louis.

People say nurses should be tough as nails — single-minded and unaffected by the environment around them or the system they serve in. Do the right thing no matter the policies or practices in your workplace or among those you serve. My experience tells me differently. Structures and systems in that other world were the most difficult to bear, and the gap between the two worlds seemed unbridgeable. It was a painful realization, but it caused me to focus my pursuit of justice on the root causes of disparities.

The lines between those root causes (often referred to as the social determinants of health) and the physical manifestations of poor health in populations and individuals aren't always clear. For example: If the school system is failing to provide special services to a child with lead poisoning under my care, do I advocate for her? Do I close a lead poisoning case when the child's blood lead level is below the threshold, even if the family still lives in a decrepit home full of lead-based paint? Isn't assisting the mother in accessing education or employment just as important as ensuring her child is receiving the appropriate therapies to ameliorate the effects of lead poisoning?

When working among those on the margins, our roles are less clear, less rigid than in health care services for those safely in the center. Sometimes we use our nursing position as leverage to advocate for the families and community in ways that others cannot.

Another essential lesson I took to heart had to do with teamwork. I couldn't do it on my own. Nurses can't do it alone. Even the vast world of health care can't serve the vulnerable resilient on its own and expect people to be healthier. The issues are too big, too far-reaching, too entrenched. Collaboration is essential. Learning to foster partnerships is crucial to serving the marginalized, especially collaboration outside formal health care providers and systems. Some of these partnerships will be with very unlikely stakeholders, such as an ex-convict father who is concerned about his child's lead poisoning, or a nonlicensed contractor doing good work despite being undercut by a business getting away with shoddy work in poor neighborhoods.

After six years, I left the health department, studied for an MPH degree, and am now in higher education and volunteering in two organizations that serve uninsured patients. In my higher education role, I get to educate future health professionals on the importance of partnering with marginalized communities and supporting the goals of population health. My time in the health department instilled in me a desire to push future providers to the margins themselves and to support community agencies in serving their populations better. At the same time, I cannot forgo direct patient contact, since my heart also yearns to touch individual lives in need of grace, healing and advocacy.

The ultimate lesson learned was that while I may not be able to do anything about the injustice in the world, I can always put my voice with those to whom no one listens. It is not a demonstration of great power, human ingenuity or nursing knowledge, but evidence of humble compassion that eventually loosens the grip of oppressive people and systems. Isn't that method what shocked people about Jesus, anyway?

We need nurses ready to go into the field. Because we are such a trusted profession, we can go where no one else is allowed or wanted: war-torn nations, ghettos and barrios, even Congress or ivory towers. Healing the sick is a calling that gets us into the most broken places. Then we can bring in all of our collaborating partners to make real and sustainable impact that goes beyond curative care. Put on those scrubs, and the best parts of the world open up to you.

ANNA HARDY is community coordinator in the Center for Interprofessional Education and Research, Saint Louis University, St. Louis. In January 2016, she will join the St. Louis County Department of Public Health as a nurse home visitor in the Nurse-Family Partnership program.


Nurses at the Margins

Copyright © 2016 by the Catholic Health Association of the United States

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