UW nursing professor Josephine Ensign shares her experience of being homeless and serving homeless people
Josephine Ensign, associate professor at the UW School of Nursing, has intimate experience with homelessness. She has worked with homeless people throughout her career, starting as a nurse practitioner. She was also homeless herself at one point in her life.
As she portrays in her new memoir, “Catching Homelessness: A Nurse’s Story of Falling through the Safety Net,” (She Writes Press, 2016), her experiences with homeless people, coming to see them as real, valuable people, caused her eventually to question and reject the “charity” approach with which she started her career.
In the epilogue to “Catching Homelessness,” Ensign visits the “social services” section of the Richmond, Virginia, cemetery, where several of her early clients were buried. She writes: “I’ve been a nurse for almost thirty years. I crossed professional lines ... I caught homelessness. I became a broken body on my own nightmare conveyor belt ... Lee ... the black man with aids for whom I was named next of kin — Lee got me to where I am today.”
What do you teach at the School of Nursing?
I teach and I love community health nursing, [like the] nurses going across rooftops in New York City in the early days and doing outreach, not asking permission, just doing it. I teach the community public health nursing undergraduate course. And I teach graduate-level health politics and policy, as well as a health policy combined with a service learning course.
Describe how you got here, from being a nurse in a charity clinic to a professor of nursing.
I grew up in the South, in a progressive family but very much a Christian worldview. My first exposure to homelessness was at Oberlin College. I was a big sister for a former street-involved youth. That really opened my eyes.
That was the early ’80s and the huge deinstitutionalization and Reagan years, the perfect storm for the increase in homelessness. I decided to work with people who were involved with homelessness and had that whole Christian do-gooder kind of a thing — that was my identity. It was missionary work right in my hometown in Richmond [Virginia].
This was the beginning of the HIV-AIDS epidemic. I ran this health care for the homeless clinic [the Street Center] in a multiservice agency with very progressive people like Sheila Crowley, who just retired as CEO of the National Low-Income Housing Coalition. It was my exposure to people who were real humanists and activists and butting heads with the very right-wing conservative, Jerry Fallwell types paying my salary.
I started questioning the Christian faith, things that were rubbing up against my own values in terms of giving nonjudgemental care to people who were different: gay, lesbian, bisexual, transgender, although we didn’t use that term back then. I had always been a feminist in terms of women’s health rights and I had a major falling out with the minister who ran the clinic. He was saying I couldn’t advise women on options counseling, couldn’t refer for abortion, that people with HIV-AIDS, I needed to make sure that they repented of their sins before they died.
I was this starry-eyed, “Hey, I want to do social justice health care work, just leave me alone and let me do this work.” It just spiraled down from there. Anger turned inwards became a serious depression. Virginia as a state has some of the worst mental-health services, even for people who have health insurance. I spent six months couch surfing, living in my car. I got fired from the clinic, didn’t have a job, didn’t have a stable place to live, was acting out in all sorts of ways, and my marriage broke up. Career counseling at the women’s center at University of Richmond and moving to Baltimore was what really started to get me stable.
How did you end up in Seattle?
I was a student at Hopkins, working with street-involved young people in Baltimore, doing health care, clinic-based and street-based health education and outreach and my dissertation work as well. I had a son who was living with his father, who is a minister. I wanted my son back in my life and I needed a stable job for that and I saw a flier for a job here. It was just on a whim, and they referred me.
Seattle was a much more progressive place for being a single mom, for doing the kind of social justice work that I wanted to do. I met Nancy Amidei [a professor at the UW School of Social Work], a local legend, when I came for my informational interview and it was really Nancy, because she’s this glass-half-full, roll-up-your-sleeves, we-can-do-this kind of a person.
Given all these experiences, what is the biggest challenge involved in providing health care for poor and homeless people?
Our non-system of health care. Obamacare, the ACA (Affordable Care Act), was a compromise, but a step in the right direction. There’s going to have to be incremental adjustments and change. It’s really unfortunate that the Supreme Court [ruled] on the side of states’ rights and allowed them to opt out of the Medicaid expansion. We now have really good data that show that the states that did sign on for Medicaid expansion and wraparound services have definitely improved health care access and down-the-road health- care outcomes for people who are poor and involved in homelessness.
In your work in Richmond, you became friends with several people living in an informal tent encampment near your clinic. What are your thoughts about tent encampments as shelter for the homeless?
I have a tent encampment right in my neighborhood. I’ve been involved with our neighbors who are afraid of “catching homelessness.” We’re finally going to be hosting Tent City 3 next winter quarter, which our students have worked really really hard on for a long time.
One of the homeless activists in Portland at the National Health Care for the Homeless Conference about a month ago said that there are tent encampments that are like “Lord of the Flies” and there are tent encampments that are extreme utopias. I’m trying to work more towards the utopia. I’m really impressed with Tent City 3. They have worked out lots of these issues. Some of our nursing students did basic foot-care clinics at Tent City 3. The students were picking up on what made that such an inviting and healthy community, an environment that we can actually learn from in our own.
What makes the difference?
Balanced self-governance. Like anything else, there can be egomaniacs who are not about real community-building. That can just drive it down a really bad place. Good self-governance and attending to diversity of voices, having women, if there are going to be families, working with public health, working with the sponsor to have good hygiene resources, finding out what people need, have a community board. Have different kinds of things like AA meetings that people want to access, and then attending to how the place looks and feels beyond the minimum of safety.
What about informal encampments, like the one in Richmond?
We’ve had them a very long time. It’s that balance in terms of civil rights and civil liberties. But I feel that the tent encampments that are erring on the side of “Lord of the Flies” are a danger to people who are there as well as to the entire community. In that case, I think something has to be done. But not policing so much as having other options that are actually something that people want and that’s realistic for them as alternatives. I would not want to be the mayor. It’s a huge dilemma.
The implication of your memoir’s title is that people are unreasonably afraid of “catching homelessness” and poverty. But you “caught” it, not so much from contact with homeless people as because the people who paid you had a negative view of the homeless, seeing them as not worth saving.
Also, [it was] professional burnout. It’s really hard work. Sheila Crowley, I remember specifically she and I butting heads, because I had staff who would come to the clinic [for treatment] and I would realize that we didn’t have any structure to support the mental health of the people who are doing this frontline service.
I partly did “catch” homelessness because of not having adequate resources. Her response at that point, which I’m sure she would change now, is, “We’re so privileged. We need to be taking care of people that do not have privilege.”
The other part of “catching homelessness” that I was trying to pull in was the safety net that we talk about. It’s supposed to be that [for] people that fall off the cliff of good health and well-being, we have these social services and health care safety nets.
You write very poignantly about the people you knew at that clinic who had died.
Larry Pagnoni, the head of a sister agency at the Street Center, started keeping a list. I would get reports from the hospital or find out from other patients, we all would. He was, like, “We need to remember people and keep this list.” I still have that list, a stark reminder. One of the volunteers for Freedom House, that Larry was the head of, killed himself. And so for me, all of a sudden: “Do I add him to the list?” I believe in good deaths. I’ve actually been there in the room as a nurse with good deaths. But for the most part, these are not good deaths. They’re completely avoidable. People die violent, lonely deaths. It’s that part that is really difficult.
I take very seriously my role as a mentor and a teacher interacting with future generations of nurses, physicians, social workers, anybody in the health professions, of helping them realize that it’s not selfish and actually part of being a good health professional, having some kind of healthy outlet for reflecting on and working through difficult things that come up with your work. I’ve gotten into much more of a health humanities and reflective writing, or reflective drawing — some people don’t like to write a lot — or poetry.
I have been doing that for the last 10 years, in-class, low-stakes writing. They don’t get graded, but they get credit for it. It increases people’s learning, because they’re making those personal connections. I get feedback from students years later that it has been really essential for them as they start their careers. Having that be OK and actually supported sends a message. What draws you to the work that you’re passionate about in health care can be a good thing. It can also, if you’re not attending to it, be your downfall.