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The Gulf of Mexico disasters of 2005, replayed in 2010 in man-made form, brought into sharp focus and stark relief, for the entire world, the widening chasm between the “haves” and “have-nots” in the US. In American poet laureate Dana Gioia's classic essay on why the situation of poetry is of consequence to the entire intellectual community, he wrote, “A society whose intellectual leaders lose the skill to shape, appreciate, and understand the power of language will become the slaves of those who retain it—be they politicians, preachers, copywriters, or newscasters” (Gioia 2002, 17). As public health scholars and practitioners, our commitment to social justice, equality of opportunity, health enhancement and disparities elimination, locally and globally, infuses our work, and, for many, our activities during our discretionary time as well. Melding of messages delivered through scientific endeavor and poetic reflection may serve to inspire, direct and catalyze the social change needed to make progress toward these lofty, and attainable, goals and aspirations, to manifest then-Senator Barack Obama’s fiery declaration in his 2004 Democratic Convention address of the “audacity of hope.” As a capella women's music group Sweet Honey in the Rock asserts in Ella’s Song, “We who believe in freedom cannot rest….”

As public health professionals, we place disproportionate emphasis on the science driving the development of health interventions, and devote insufficient attention to the science of disseminating that knowledge to increase individual and societal adherence to healthy practices. Furthermore, most health decisions are emotionally and socially, versus intellectually or cognitively, driven! As resources inexorably constrict and need relentlessly grows, we must increase our efficiency by living our professional convictions—socially, economically, politically and spiritually, through the “scholarship” of engagement. As Gandhi asserted, “we must be the change we wish to see in the world.” And we must marshal all of our talents, forces and resources, the seen and the “unseen.”

My poetry, a mix of self-discovery, social commentary and health advocacy, with frequent use of sports as a metaphor, sometimes veers toward the political. But, of course, as a physician for over a quarter-century—of populations now, not individuals—health broadly defined (physical, mental, emotional, spiritual, financial) surfaces in most of my work. And basketball has become a coda for identification with black culture, as its visible and exquisite manifestation of excellence, assertion of dominance and channeling of anger and frustration symbolizes our hopes and dreams as a people. Especially at the intersection of race and gender, as in We, Too, Are Ballas

...thriving, striving and deriving
the last ounce of energy, determination
frustration at any limitation!
Engendering fearlessness
in other arenas,
in which ovaries
give us competitive advantages
over cojones.

During the run-up to the 2008 election, President Barack Obama used his love of basketball to signal his blackness when some African Americans questioned his identity or cultural grounding. Basketball also supplies the “props”—assertion of insider status—to criticize our own. Like the all-too-common sexual risk-taking and early childbearing among young black people that bubbled up in B-Ball Blues.

…These ballin' brothas
Many, not all
Plantin' babies
'Thout committin'
To the sistuhs
Carryin' 'em...
Non-men
Disingenuous boys
Don't they know
That the anger
Of those sistuhs
Toward them
Will be visited
Upon their sons
These ballin' brothas
Many, not all
With so much talent
Drive, discipline
And sheer power
Caught up in toys--
Rides, Cribs,
Threads,
Boxes
Rather than politics,
Literature, spirituality,
Education, health
NBA is mo' letters
'N most of 'em
Can handle
At one time...
These ballin' brothas
Some, a few
Are men...
Who should be celebrated
With Martin, Malcolm and Marcus…
Not so much
For this career
As for that
Which is sure
To follow

I’d like to advance my 7 A’s of Constructive Public Health Action, against chronic disease, violence, social injustice and the many other threats to the health of our communities.


1. Activism

No, it didn’t go out in the ‘60s. We need it as a way of channeling our righteous anger and frustration at a sociopolitical system hostile to the empowerment of women, older people, younger people, people of color, people who aren’t affluent or Christian or heterosexual, people who didn’t go to the “right” schools or don’t live in the “right” neighborhoods. Rather than at ourselves through violence, substance use, depression, sexual risk-taking and ill-prepared childbearing. Let me emphasize that activism takes individual (e.g., letter-writing) and collective (e.g., organized protest) forms, creating moral and political imperatives. Finally, the Occupy movement in its outrage at escalating social inequality is matching the energy of the Tea Party!

My activism these days generally takes the form of intellectually challenging the status quo. In many instances, it’s no more than figuring out ways to scientifically document common sense observations that most people who inhabit non-affluent communities make daily. For example, we published a study several years ago examining the contribution of commercial advertising to obesity-related disparities and found, to no one’s surprise, that schools and day care centers in low-income zip codes have many more ads for sugary beverages and fast food than those in wealthier zip codes (Hillier et al. 2009; Yancey et al. 2009). We also found similar distributions of ads for sedentary products and services, e.g., TV shows, films and cars. And ads promoting physical activity were nearly non-existent in any area. There were so few ads in affluent white communities that we had difficulty finding a zip code for inclusion. In a similarly conceived project, we quantified the amount of moderate to vigorous physical activity that kids get at school during PE—on average, 6-8 minutes during a 30-minute class and even less in low-resource schools (UCLA 2007). For Lettin' Me Play arises from my gratitude to those who opened the doors and provided the guidance, allowing me to "get in the game" of academic public health practice.

Mos' times
They don' even let us
Get in the game
Don' let us
Showcase our wares
Tell us
We're weak
Crush
Our spirits
Deny
Our feistiness
Subjugate
Our vision
Scrutinize
Our style
Criticize
Our every move
Relegate us
To the sidelines
To cheer on
The action
Under the guise of
Protectin' us
Can't run
'Less we get in the game
Can't score
'F we don' get the ball
Y'all made sure
That didn' happen
To me

2. Sociopolitical and Historical Awareness

People who do not understand the historical context of their current standing suffer their ignorance in lost collective self-esteem and pride in accomplishment. All of the great leaders of our communities, such as Susan B. Anthony, Angela Davis, Eleanor Roosevelt, Shirley Chisholm, Indira Gandhi and Barbara Jordan, have tried to address and influence our hedonism, materialism, consumerism, identification with the aggressor, competitive “crabs in a bucket” mentality and other destructive values we’ve foolishly embraced. Suffice it to say that people who don’t know their history are destined to repeat its mistakes. Ain' Like There's Hunger speaks to many of these issues through the lens of the sociodemographic and environmental conditions underlying obesity disparities (Yancey 2007; Yancey et al. 2006; Yancey & Kumanyika 2007).

Sweet tooth
Salt tooth
Chocolate tooth
Jonesin’ for fries,
Triple deck Mac,
Coke and pork rinds
But no walkin’ tooth
Swimmin’ tooth...
Weight liftin’ tooth
After all,
Ain’ like there’s hunger…
Mind numbin’ early gig
Second gig even worse
Kids in between
Gotta be fed
Read to
Homework checked
Ears inspected
Dark park?
Cold out?
After all,
Ain’ like there’s hunger…
Sittin’ all day
Tryin’ to look nice
’Do costin’ thirty, fo’ty
Dollas a week
Heels and huggin’ skirt
And these fifty extra pounds
I’m carryin’ around
Stairs ’re a joke!
Walkin’ at lunch?
Humidity wreck my hair
After all,
Ain’ like there’s hunger…
So if bein’ a nation
Of couch potatoes
Or “mouse” potatoes
Is really that bad
Why don’t they
Make it easy?
Perk me up
Since I’m usually down
Where I work
On the “company’s” clock
Yeah, how ‘bout a little recess?
Like when we were
Kids in school
I might take a stroll
On “their” time!
Or find some jammin’ tunes
For my little group
Packin’ some
extra pounds
Been awhile since we got down!
“Shiftin’ & movin’ &
swingin’ & groovin’”
Get that natural high flowin’
Now that might make me hungry
For more!

3. Advocacy

We all have some knowledge or power in some arena that can help somebody in need to help themselves, be it a relative, friend, patient, co-worker, neighbor or somebody we just run into in the grocery store. I somehow survived the most challenging advocacy project of my life—navigating the health care and social services bureaucracies to manage my mom’s last decade of life. I wrote She Went Away out of the anguish of protracted loss imposed by Alzheimer’s, and in celebration of a life well-lived.

Alzheimer’s
Steals
Robs
Takes
Drains
Eradicates
Insidiously
Assiduously
Unrelentingly
A knowing smile
An arched eyebrow
A “stop you in your tracks” stare
A hearty laugh
A nervous glance
A sarcastic chuckle
A made-up word
Good glugallywogallywomblebot!
1% here
2% there
She
Slipped out
Seeped through
Was spirited away
Like sweat through her pores
Like tears through her eyelashes
Like blood from her veins
Like milk from her breasts
Like saliva from her lips…
The memories
Of a life well lived
The pride
Of a life much appreciated
The confidence
Of a life much heralded
The dreams
Of a life lived vibrantly…
But not
The love
Of a life well connected
The presence
Of a life lived reverently
The hopes
Of a life well anchored
The satisfaction
Of a life lived appreciatively…
At what point
Has the person
Seeped out
Slipped through…
The cracks
The fissures
The crevices
The quakes
The fault lines…
At what point
Is the person
No longer there?
Behind the façade
Of the vacant stare
The hollow laugh
The angry countenance
The desperate clinging
The empty smile
The desolate look
The crumbling features
The reedy voice
A Hollywood set
Windows without sashes
Streets without gutters
Lawns without sprinklers
Chimneys without flues
Rain without clouds
Snow without frost
Grass without dew
Houses without foundations
When is a life
No longer worth living?
On some level
She knew
And she left
And she spared me
An Alzheimer’s death

4. Physical Activity

Sedentariness, suboptimal nutrition, smoking and other substance misuse, and high-risk sexual activity account for most chronic disease risk and disparities, including the high blood pressure and diabetes leading to most of the need for organ transplantation. And there is a "multiplier effect" of preventive practices by health care providers and other opinion leaders and gatekeepers. Recapturing Recess corrals a bit of the energy and exuberance we've lost touch with, helping to frame physical activity as something people want, not just something we think they need, as our studies of Instant Recess® demonstrate (Yancey 2010; Barr-Anderson et al. 2011; Maxwell et al. 2011; Whitt-Glover et al. 2011).

Now I know
Y'all can remember
The recess bell
The wave of exhilaration
The sigh of relief
The sheer release
The transformation
Of fidgeting
Into linear motion
Raise up your hands
If you can remember
All that pent-up energy
Exploding
Into air and space
Leaping
Into wind and sunshine
Launching
Onto grass and hardwood
Soaring
Into goals and hoops
And if you can recapture
Even a little of the joy
Of unbridled movement
Then just maybe there’s hope
For the couch potatoes!
Those of you too worn down even to fidget!...

5. Spiritual Attunement

Spirituality has offered respite and rejuvenation throughout the millennia in the struggle against oppression and inequity. Speaking Truth to Power testifies to my core beliefs, with a nod of support to Anita Hill, as it was written during the Clarence Thomas confirmation hearings.

Thanks, Cornel
And Samuel...
And Daddy
For remindin' me
That love's
What it's all about...
I can't win at hate
'Cause the devil's
Too fickle a master
Got no integrity
'S soon stab you in the back
'S look ya in the eye
I'm on God's side
I was born in faith
My folks'
And my people's
And in faith
I shall live or die
But not waver
I shall speak truth to power
With love
Stan' for somethin'
Not fall for nothin'
Truly live
And when I become
Too much of a threat
Fall for somethin'
Because this mortal life
Is such a small part
Of our eternity
And recognizing only
One Higher Authority
Makes life so much simpler
And more easily relinquished

6. Altruism

A reporter for the Philadelphia Inquirer introduced his article about a local drive to recruit bone marrow donors a few days before Christmas in 1992, (Kanaley 1992) writing, “As the line of children snaked toward Santa, and city shoppers shouldered their way between chain stores, an occasional hero slipped into a white tent in the Gallery yesterday to get stuck with a needle and have a teaspoon of blood drawn. ‘Do I get paid for that?’ inquired Tyrone Lucas, 19, of South Philadelphia, as he hesitated at the entrance of the tent set up by the city health department. The answer was no. But Lucas went in anyway. ‘It was all right,’ he said a few minutes later. ‘I feel good to be into something.’" I’ve heard people who actually donated marrow say that the “high” lasted a year or two. This speaks to the connectedness that we need for grounding and well-being. And that brings me to a poem near and dear to my heart that speaks to the research interest that brought me into public health, namely role modeling. In order to move our lives in the direction we envision, we need to exchange a lot of Currency, beyond just the flow of dollars. 

I gave Akil
The spot I earned
In a pick-up game
You know, b-ball
To a kid
That's like money
Currency
... I gave Robyn
A heartfelt compliment
Told her
She's the best
Student I've known
To a kid
That's like money
Currency
Akil gave me
An ego boost
Told some other folk
I taught him to play
You know, b-ball
To me
That's like money
Currency
Robyn gave me
The ultimate gift
Told my aunts
She wanted to be
A model/doctor
Just like "Aunt Toni"
To me
That's like money
Currency
All that currency
Exchanged between us
And nobody
Spent a dime!

That poem was inspired by a particular pick-up basketball game in a park here 10 years ago that I sat out while my godson played in my place. It was a bit like watching the Michael Jordan of the ‘90s raise his game at will in the last few minutes of a tight contest, which reminds me of the incredible empowerment associated with a powerful mentor communicating a belief in you. Sometimes that empowerment occurs through no personal communication at all, but by our choice of a powerful other as a role model, most often with whom we share sociodemographic similarities, like gender and ethnicity. We've been able to demonstrate this positive association between role modeling and healthy outcomes in studies of Los Angeles County and California adolescents (Yancey et al. 2002; Mistry et al. 2009; Yancey et al. 2011). I believe that the provision of a diversity of images of powerful others, self-efficacious others, is critical in addressing racial/ethnic health disparities. 


7. Authenticity

To understand who we are, we must understand our past, not only individually, but collectively—our “ancestral capital.” Is a poetic voice hereditary? Perhaps the facility with language, agility of intellect, reality of memory, and lability of mood are. But the talent’s the small part of the poetic spirit. The drive, determination, dedication and discipline to seek our mission, follow our passion, and live our prayer are wholly a function of the role models and mentors whose paths we cross or who cross ours.

My aunt, Antronette (Toni) Hall Brown, was one of my first role models, and my mother named me after her. She earned her B.A. in English from the University of Kansas in 1938 and her M.Ed. from Columbia University in 1956, after 6 summers of commuting to New York from Kansas City by car. She was a pioneer in the development of adult basic education in promoting literacy. She wrote “A Perfect Day” as a college freshman, and it was published in the newspaper of her former Kansas City, KS high school 75 years ago. She died five years ago at age 90, but her spirit lives on and her work is carried on by the minions of us she inspired. She, indeed, lived…

A Perfect Day

God, give me strength to face this
   day
The obstacles that block my way,
Take Thou hand and lead me to
The things that make me more like
   You.
Show me a deed, lead me apart
To bring happiness to some sad heart,
Fill my odd hours with all that’s true
Pleasure and labor – the whole day
   through.
Thus may my day be pure and
   Bright;
Teach me to know the wrong from
   right
And when shadows fall, I want to
   Say
That I have lived a perfect day.

I wrote this tribute to Toni, capturing not only my sense of loss, but also the focus of our family values on inter-generational investment in public service.

We Are One…Continuum:  a river nourishing the world

...I looked into the soul of my future today
And of my past
What’s in a name?
The power to shape
Mold, sculpt
Subliminally
Conscientiously
But not entirely
Consciously
Communication of a dream
Born not long after
The birth of the dreamer
I looked into the spirit of my future today
And of my past
A bright courageous future
Spanning many years
Of personal satisfaction
Human interaction
Scientific recognition
And public reaction
A future
That she
And they
Fostered
And foreshadowed.
Only she won’t be there.
And she’s the only one left.
Toni (Antronette) Yancey, MD, MPH is Professor, Department of Health Services, and Co-Director, UCLA Kaiser Permanente Center for Health Equity in the School of Public Health, with research interests in chronic disease prevention and health promotion policy intervention. She serves on the Board of Directors, among others, of the Partnership for a Healthier America, supporting First Lady Obama's Let's Move campaign. Her second book, Instant Recess: Building a Fit Nation 10 Minutes at a Time, was released in November 2010.

References

Barr-Anderson, D.J., M. AuYoung, M.C. Whitt-Glover, B.A. Glenn, A.K. Yancey (2011 January) Integration of short bouts of physical activity into organizational routine a systematic review of the literature. Am J Prev Med. 40(1):76-93.

Gioia, D. (2002). Can Poetry Matter? St. Paul, MN: Graywolf Press.

Hillier, A., B. Cole, T.E. Smith, A.K. Yancey, J.D. Williams, S. Grier, & W.J. McCarthy. (2009 December). Clustering of outdoor advertisements for unhealthy products around child-serving institutions: A comparison of 3 cities. Health & Place. 15(4):935-45.

Kanaley, R. (1992) Mall Bone Marrow Drive Looks to Minorities African Americans Have Received Only 20 of 1,400 Transplants Since 1987. Philadelphia Inquirer Dec 20: B10

Maxwell, A.E., A.K. Yancey, M. AuYoung, J.J. Guinyard, W.J. McCarthy, & R. Bastani. (2011 September). Dissemination of organizational wellness practice and policy change: A mid-point evaluation of the L.A. basin REACH US Center of Excellence in Eliminating Disparities. Prev Chronic Dis. 8(5):A115.

Mistry, R., W. McCarthy, A. Yancey, Y. Lu, M. Patel. (2009 March). Adolescent resilience and patterns of health risk behaviors in California. Prev Med. 48(3):291-7.

UCLA Center to Eliminate Health Disparities and Samuels & Assoc. (2007 January). Failing Fitness: Physical Activity and Physical Education in Schools. A policy brief from The California Endowment. 

Whitt-Glover, M., S.A. Ham, A. Yancey. (2011). Instant Recess®: A practical tool for increasing physical activity during the school day. Prog Community Health Partnersh. 5(3):289-97.

Yancey, A.K., W.J. McCarthy, G.G. Harrison, W.K. Wong, J.M. Siegel, J Leslie. (2006 May). Challenges in improving fitness: results of a community-based, randomized, controlled lifestyle change intervention. J Womens Health (Larchmt). 15(4):412-29.

Yancey, T. (2010) Instant Recess: Building a Fit Nation -- 10 Minutes at a Time. Berkeley, CA: University of California Press.

Yancey, A., B. Cole, R. Brown, A. Hillier, J. Williams et al. (2009). A cross-sectional prevalence study of ethnically-targeted and general audience obesity-related advertising. Milbank Quarterly. 87:155-84.

Yancey, A.K., D. Grant, S. Witt, N. Kravitz-Wirtz, & R. Mistry. (2011). Role modeling, risk and resilience in adolescents: Evidence from the CHIS. J Adol Health. 48:36-43.

Yancey, A.K. & S.K. Kumanyika. (2007). Bridging the gap: Understanding the structure of social inequities in childhood obesity. Am J Prev Med. 33(4S):S172-74.

Yancey, A., J. Siegel, & K. McDaniel. (2002). Ethnic identity, role models, risk & health behaviors in urban adolescents. Arch Pediatr Adol Med. 156:55-61.

The aftermath of war affects the health of individuals who served, their families and the communities in which they live and work. Since September 2001, roughly two million troops have deployed in support of the wars in Iraq and Afghanistan. Of these, about 1.2 million have separated from active-duty military service (Bilmes 2007). For many of these men and women, the transition from active-duty military to post-deployment civilian life is complicated by long separations from family and friends, interruptions to employment and education, physical injuries, and the ‘invisible wounds of war’ such as traumatic brain injury and post-traumatic stress. For some, serving in combat can exact the highest price of all; current figures in the U.S. estimate that war veterans are at least 2 times more likely to commit suicide compared with non-veterans (Mills et al. 2011). Meeting the needs of returning combat veterans and promoting their physical, psychological and emotional health will be one of the greatest public health challenges of the next 50 years.

Despite widespread support for deployed troops, there remain formidable challenges to successful reintegration of returning veterans into family and community. With less than one percent of the U.S. population currently serving in the military, many civilians lack a basic understanding of military culture and values. This contributes to a disconnect between veterans and the very people who most want to help them—family and friends,  healthcare providers, employers, educators and community organizations—leaving many veterans feeling isolated and alienated at a time when they are most in need of connection to others.

Because you have listened to my story, I can let go of my demons.
-from the Japanese folktale, ‘The Tale of Genji’ (Shikibu)

The impulse after a major life transition or traumatic event is to create a cohesive narrative that will impose order onto chaos, and to share our stories with others in order to lessen our burden and not feel so alone. When we get stuck, as many combat veterans do, when we don’t know what parts of our story are safe to share or what audiences are safe to share with, it creates a barrier between us and the rest of the world. The result is that our story can get stuck in a particular moment, a negative moment, resulting in deep feelings of isolation, alienation and hopelessness. When we break through this barrier and share our story with an audience who makes us feel safe and respected by withholding judgment, accepting our story at face value, and showing compassion for our experiences, this leads to a kind of communalizing of the experience that can result in healing not just for the storyteller, but for the listener as well.

The arts and humanities have a pivotal role to play in harnessing the power of narrative—from the classic storytelling of ancient Greek plays to Civil War-era military logs to the individual life stories, blogs and first-person accounts of today’s veterans—to bridge the divides of time, culture, and personal experience. Creating a framework for shared understanding is critical to promoting health and healing for veterans and their families and allowing veterans to see how their stories fit within the universal themes of war. For civilians, knowing veterans’ stories can expand knowledge of the core values common to those who have served and counter the many stereotypes that abound; the “heroic soldier,” the “damaged and unstable veteran,” the “trained sniper with no marketable skills” (Dewan 2011).

To this end, a number of innovative programs in our region and around the country are focused on providing veterans with the tools to tell and share their stories of military service and homecoming. One of the authors (GT) is a folklorist and researcher at the Philadelphia VA Medical Center who recently completed a study investigating the use of Life Story review to reduce social isolation and anxiety among combat veterans. Dr. True also uses Photovoice methods to enable returning veterans to communicate their healthcare needs and preferences to  healthcare providers and policymakers through visual and narrative images (www.cherp.research.va.gov/).

At the National Intrepid Center of Excellence in Bethesda, MD, the National Endowment for the Arts and Walter Reed National Military Medical Center have teamed up to create a pilot program where patients with traumatic brain injury or post-traumatic stress will be partnered with authors and therapists to use writing as part of the clinical rehabilitation process. The aim is to allow veterans to manifest their trauma in the form of poetry, journals, diaries or stories in order to confront a traumatic experience and manage it (www.nea.gov/national/homecoming/index.html).

Warrior Writers is a Philadelphia-based, national nonprofit whose mission is to provide a creative community for artistic expression for veterans and their ‘allies,’ and to “bear witness to the lived experiences of warriors” (www.warriorwriters.org). Warrior Writers organizes and facilitates retreats that bring together veterans, military families, artists and community members to write and make art, and to perform and exhibit veteran-centered works. Warrior Writers and the Mural Arts Program of Philadelphia are partnering to host a series of art and writing workshops that will result in the creation of a mural, “Our City, Our Vets.” The overall goals of the project are to create a safe space for veterans to share their stories, and to encourage dialogue between veterans and civilians to facilitate reintegration of veterans into their communities (www.muralarts.org/ourcityourvets). Warrior Writers has also collected and published three anthologies of veterans’ poetry, prose and artwork; these works provide an invaluable window into the range of backgrounds, experiences and perspectives of veterans.

One of the authors (RP) directs the Veterans History Project (VHP) of the American Folklife Center at the Library of Congress. The goal of the VHP is to collect, preserve and make accessible the personal accounts of American war veterans “so that future generations may hear directly from veterans and better understand the realities of war” (www.loc.gov/vets/). The VHP provides materials and training to volunteers who wish to collect stories from veterans in their family or their community. VHP has archived an important collection of oral histories and personal documents of veterans from WWI to the current conflicts in a searchable database that is open to the public. According to feedback from participants, positive outcomes of involvement include the enlightenment that comes with the intergenerational interaction of recording a veteran’s wartime experiences. Some of the older veterans have held back these stories for decades. Many family members have expressed their gratitude at finally knowing ‘the full story’ of their veterans’ wartime service. The veterans themselves relate a degree of pride, along with some relief, that their personal account will be permanently preserved for the nation at the Library of Congress.


A number of programs tap into the wealth of ancient and historical writings about war and its aftermath; two notable examples include a national initiative called Theater of War and a Philadelphia-based project at the Rosenbach Museum and Library. Theater of War (ToW) presents readings from two plays by Sophocles to military and civilian audiences throughout the U.S. (and internationally); each performance is followed by a town-hall style discussion led by a panel of local experts including a veteran, a family member of a veteran, and a mental health provider who works with veterans. The aims of ToW are to de-stigmatize the psychological injuries of war and increase awareness of post-deployment psychological health issues (www.outsidethewirellc.com/projects/theater-of-war/).

Locally, the Rosenbach Museum and Library has begun a new initiative called “Families Affected by Wartime,” which will use their extensive collection of correspondence, military logs and other materials from the Revolutionary and Civil Wars to connect with today’s veterans and their family members (www.rosenbach.org). The program will focus on building programming and curricula around historical documents; target audiences include children at a local elementary school, teenagers with a parent who has deployed, and student veterans at area colleges and universities. The intention is to connect veterans and their family members to the museum and its collections, and to offer the museum as a place for public dialogue about what service means and how wartime deployment affects families and communities.

Finally, there are numerous personal accounts from veterans about military service, homecoming and post-deployment struggles. One of the authors (SC) has blogged about and published an account of his year-long deployment to Iraq, injuries sustained after an IED (Improvised Explosive Device) blast, and subsequent challenges after coming home (www.serviceandsacrifice.net). According to 1st Lt. Console, who first started writing about his experiences as part of his involvement in the Hospitalized Veterans Writing Project (www.veteransvoices.org/), the act of organizing and writing down his memories helped him to make sense of his personal experiences in combat, and also represented an effort to capture one version of the history of his unit during that deployment. Detailing his experiences with mental health services and treatment for post-traumatic stress and traumatic brain injury, he also provides a list of resources for other veterans and their family members with the hope that they will learn from his experiences and feel less isolated and alone.

The nonprofit Wounded Warrior Project convened a conference of veterans and family members to assess continuing needs; participants of this Warrior Empowerment Summit expressed frustration with barriers to accessing veterans’ benefits including education, employment and treatment for post-traumatic stress. Lack of understanding of “warrior culture” and combat experiences among  healthcare providers, employers, educators and non-veteran students—in essence, an absence of cultural competency—emerged as a major obstacle to veterans feeling ‘at home’ in civilian contexts (Ibson 2010). Veterans’ narratives, photos and art can be employed as powerful way to engage and educate civilian audiences in a way that is visceral and lasting. For example, 1LT Console’s photograph of men in his unit ‘at rest’ (figure 1) conveys important information about the conditions in which combat veterans lived and how those conditions might impact on their sleep patterns, physical health and mental wellbeing after their deployment.

The programs and approaches described above have in common the use of writing and narrative as a way into accessing, retelling and addressing potentially sensitive or traumatic memories in a non-confrontational manner that allows the teller to control the pace and extent of revelations. This is important especially for combat veterans with post-traumatic stress who are often reluctant to engage in traditional, evidence-based therapies. A 2010 study of recently returned combat veterans who received a diagnosis of post-traumatic stress found that less than 10 percent completed the recommended course of clinical treatment; barriers to treatment included concerns about stigma of a mental health diagnosis and reluctance to discuss traumatic events (Seal et al. 2007). Engaging veterans in telling their stories, teaching civilians how to listen and how to talk with veterans, creating safe spaces for sharing narratives, and using these narratives to educate those who wish to help veterans—activities taking place in the programs described above—all have the potential to help veterans bridge the transition from military to civilian life, to reduce the stigma of mental health diagnoses and treatments, and to highlight how the skills and knowledge attained through military service can be of value to society in a wider context. Perhaps most importantly, creating and sharing narratives builds connections and reminds us that no one is truly alone in their story.

Sharing our stories can help us realize we are not alone;
there are others who are going through this.
-Pennsylvania Army National Guard member and veteran of Operation Iraqi Freedom
Gala True, PhD, is a Core Investigator with the Center for Health Equity Research and Promotion at the Philadelphia VA Medical Center and Research Assistant Professor at the University of Pennsylvania Perelman School of Medicine. As a folklorist and health services researcher, her work focuses on the role of narrative and ethnography to reduce barriers to care and improve post-deployment health outcomes for combat veterans. She recently completed an intervention study investigating the use of Life Story interviews to decrease social anxiety and PTSD symptoms for veterans of the wars in Iraq and Afghanistan. Her current work involves using visual images and first-person narratives to sensitize VA clinicians to deployment and post-deployment experiences and perspectives of returning combat veterans, and to promote patient-centered care at the VA.

Robert W. "Bob" Patrick is director of the Veterans History Project, a congressional project of the American Folklife Center in the Library of Congress to collect, preserve, and make accessible oral histories and documentary materials from veterans of World War I through the current conflicts. Bob has experience leading organizations in the areas of veterans affairs and policy development. For more than five years, he served a critical role in the National World War II Memorial project and directed the historic memorial dedication. Patrick, a retired U.S. Army colonel, had served in a number of leadership positions, particularly in the areas of administration and human resources, both overseas and in the states. He is a graduate of the United States Army War College, and he received a master's degree in public administration/public service at Western Kentucky University and a bachelor of arts in history from the Virginia Military Institute.

Samuel J. Console, former 1st Lieutenant in the Pennsylvania National Guard, served in Iraq as an Engineer Platoon Leader and Battalion Assistant Task Force Engineer in 2004-2005. During his deployment, he sustained a Traumatic Brain Injury as a result of a complex IED attack. He has written and talked about his combat and post-deployment adjustment experiences, and found the process has played an important role in his recovery.

References

Bilmes, L. (2007). Soldiers returning from Iraq and Afghanistan: The long-term costs of providing Veterans medical care and disability benefits. Faculty Research Working Paper Series, Kennedy School of Government.

Dewan, S. (2011, December 17). As war ends, young veterans return to scant jobs. The New York Times. Available at http://www.nytimes.com/2011/12/18/business/for-youngest-veterans-the-bleakest-of-job-prospects.html?pagewanted=all.

Ibson, R. (2010). Transforming VA Care of OEF/OIF Warriors' Combat-Related Mental Health Conditions: Recommendations of Wounded Warrior Project's Warrior Empowerment Summit. Report to General Eric Shinseki, United States Secretary of Veterans Affairs.

Mills, P.D., S.J. Huber, B.V. Watts and J.P. Bagian. (2011). Systematic vulnerabilities to suicide among veterans from the Iraq and Afghanistan conflicts: Review of case reports from a national Veterans Affairs database. Suicide and Life-Threatening Behavior, 41(1):21-32.

Seal, K.H., S. Maguen, B. Cohen, K.S. Gima, T.J. Metzler, L. Ren, D. Bertenthal and C.R. Marmar. (2010). VA mental health services utilization in Iraq and Afghanistan Veterans in the first year of receiving new mental health diagnoses. Journal of Traumatic Stress, 23(1):5-16.

Shikibu M., translated by Arthur Waley. (1960). The Tale of Genji. London: Vintage Publications.

 

Disclaimer: The contents of this article do not represent the views of the Department of Veterans Affairs or the United States Government.

This photograph is of Barbara (Barbie) Izquierdo’s son, two-years-old at the time Barbie took the photo. As Barbie told an audience of 800 at the Metropolitan Museum of Art in 2009 (http://youtu.be/bTpoPXZWWcU?t=1h15m30s), her son had been in and out of the emergency room in the winter of 2008. He had persistent eye infections because, without heat for the entire winter, his tear ducts would be perpetually clogged. That winter, she struggled to feed her children and herself, and while the two children shared a can of pasta, she would study the pictures on the pizzeria menus she found on her doorstep to ease her own hunger pangs.

Photo by Barbara Izquierdo, Witnesses to Hunger

Barbie’s family was experiencing what researchers call “food insecurity,” which is lack of access to enough food for an active and healthy life. In 2010, 48.8 million people in the United States lived in households experiencing food insecurity, and children are more likely to live in households that are food insecure than any other age group (Coleman-Jensen et al. 2011). Most people understand hunger as a moral and ethical issue. We ask ourselves, “Why, in such a wealthy nation, do children go hungry?” Food insecurity is also a major public health problem, as it is associated with a long list of health problems in children and adults. Young children who are food insecure are more likely to be hospitalized, to have iron-deficiency anemia, and to have developmental and behavioral problems (Skalicky et al. 2006; Rose-Jacobs et al. 2008; Cook et al. 2004).

My daughter’s health: I want everyone to see how important her health is to me.  She’s been so sick.  Her asthma started acting up and then she got cold sores and, forget it! Those are all her medications. She has to take them everyday, and one medicine she takes four or five times a day, just to keep her mouth from hurting so bad.
–Photo and Voice by Angelica R

With the money food stamps provide, I was able to feed her breakfast that morning. Without it what would she have eaten? I wanted to show that with the help she was able to eat breakfast that morning. She had cereal. She had milk. She didn’t have to go without.
–Photo and Voice by Crystal S.

Too many children get killed: A kid got shot here right around the corner from a gun control billboard. They’re trying to send a message. Nobody’s getting it. You see? I’m scared to take my kids out and be in the wrong place at the wrong time. I stay in the house.
–Photo and Voice by Virginia G

Exhibit at Russell Senate Building, Washington, DC
–Photo by Mariana Chilton

Sisterly Love: This is a picture of some of us Witnesses to Hunger showing the world our sisterly love.
–Photo by stranger with Imani’s camera, Voice by Imani, S

Food insecurity also affects school performance and educational attainment. Children who are food insecure don’t do as well in school, and can have social and behavioral issues that prevent them from learning as well as their peers (Alaimo 2000)(Frongillo, Jyoti, and Jones 2006). It not only affects cognitive function, but also emotional health; adolescents experiencing food insecurity think about committing suicide more than their peers, and parents who are food insecure experience more stress and show higher rates of depressive symptoms (Alaimo, Olson, and Frongillo 2002; Casey et al. 2004).
The pictures in this article, along with other powerful photos and videos, were taken for Witnesses to Hunger (http://www.centerforhungerfreecommunities.org/our-projects/witnesses-hunger), a photography and advocacy project begun in Philadelphia in 2008. The project, hosted by the Center for Hunger-Free Communities at Drexel University School of Public Health, was borne out of frustration that those who understand the pain of food insecurity and hunger firsthand were not included in the development of its solutions. Over 40 mothers in Philadelphia took photographs and videos of their lives and neighborhoods to create an exhibit showcasing their struggles and triumphs and their ideas for change. Some photographs depicted issues of food and hunger directly, such as a photo of a young girl eating a bowl of cereal whose mother asks, “Without [food stamps] what would she have eaten?” Others show violent and neglected neighborhoods, struggles to access work and education, the beauty and resilience of children.

The women of Witnesses to Hunger have expressed themselves as artists in many ways—they are not only photographers, but also videographers, poets, dancers, sculptors and storytellers. Their artwork is a way of connecting to others and sharing their experiences. Witnesses to Hunger is based on a participatory research model called “photovoice,” which was created so that research participants, and not the researchers, can frame the issues most important to their own lives and communities (Wang and Burris 1997; Catalani and Minkler 2010). This project represents the beginning of what we hope is a paradigm shift in the way hunger and poverty are addressed in this country, with those who have personally experienced hunger and poverty leading the drive toward solutions.

Too often, decisions about those struggling with poverty are made by those with no personal experience of being low-income, and without the input of those who have lived in poverty. Those who are low-income in the United States have frequently been left out of the political process, both by circumstance and design (Chilton et al. 2009). Rather than perceiving those who receive assistance like SNAP (formerly food stamps) or TANF (cash assistance) as passive recipients whose lives need to be directed or regulated, Witnesses to Hunger provides parents with the opportunity to speak directly with those who make decisions about such programs. The Witnesses to Hunger exhibit has been displayed at the U.S. Senate in Washington, DC, and at the invitation of Senator Bob Casey, Jr. (D-PA), and at the State Capitol in Harrisburg, PA, and will be shown in the Massachusetts State House in the spring of 2012. It has also been at a variety of educational and public venues across the mid-Atlantic and the northeast. At each exhibition, the mothers who took the photographs have an opportunity to speak, in both intimate meetings with public officials and large public events, about the photographs they have taken, their personal experiences, and their ideas for ending hunger and poverty in the United States.

This project has expanded and received attention from local, national and international media (notably, Witnesses to Hunger is featured in the documentary Finding North, which premiered at the Sundance Film Festival early this year). The overwhelming response from the media, individuals and public officials that we have seen since 2008 leads us to believe that others, too, have felt the absence of the true experts on hunger and poverty from the conversation. Parents from around Pennsylvania, as well as Massachusetts, Rhode Island and Maryland, have joined the cause, and have contributed their photographs and ideas to the traveling exhibit and website. We are creating a model that can be used by groups throughout the country to begin their own photovoice projects as they advocate for change.

The model of Witnesses to Hunger is unique in that it breaks down barriers of class, race and position and works from an understanding of our shared humanity. Witnesses to Hunger is not about “experts” speaking for a voiceless population, it is about creating opportunities for those who have been told time and again that their voices don’t matter to speak out. It is not about outsiders taking photographs of people’s struggles and displaying them to elicit sympathy or raise money for a cause. Some of our friends in the advocacy world have begun using a technique they call “story banking” as an advocacy tool: they ask those affected by the federal anti-poverty programs, or clients of a food pantry, to sit in front of a camera and share their experiences. These stories are then compiled and used by the organization to sway the hearts and minds of political staffers and the public. While we laud efforts that bring people together around a common humanity, Witnesses to Hunger is not about eliciting “stories”—it is about working with people to frame the issues that are most important to them, and ensuring that anti-poverty efforts are lead by those who have the most stake in the discussion.

This project has shown the power of the arts to contribute to a real and nuanced understanding of hunger. Those who view the exhibit often see their own neighborhoods and families reflected in the photographs—for some, this is the first time they are seeing the world with such a lens, for others, the photographs are painfully familiar. These works of art have the potential to profoundly shift the way we see and understand hunger in this country. We might be accustomed to the more sanitized images of hunger: the advertisements for canned food drives, featuring smiling children and abundant donations. In the photos of Witnesses to Hunger, we still see smiling children, but we also see the ugly, violent truth of hunger.
Our first step is to more fully grasp the pain of hunger, as well as the brilliance and dignity of those who suffer through it. Once the country understands this and can relate emotionally, intellectually and humanistically to those who have intimate knowledge of poverty and hunger, they can then recognize that the women of Witnesses to Hunger, and millions like them, are our leaders and partners. With their leadership, we can develop systemic, positively radical policy changes that are not designed to punish and regulate, but rather to treat and prevent hunger.

 

Jenny Rabinowich, MPH, is Manager and Research Coordinator of the research and advocacy project Witnesses to Hunger at Drexel University School of Public Health. For more information see: http://www.centerforhungerfreecommunities.org.

Barbara Izquierdo has been a member of Witnesses to Hunger since 2008 and has traveled around the country speaking out about her experiences as a single mother raising children on a limited income. She is profiled in the feature-length documentary Finding North, which is slated for release in early 2013.

Mariana Chilton, PhD, MPH, is Associate Professor at Drexel University School of Public Health and Director of the Center for Hunger-Free Communities. Her research focuses on child and household food insecurity among low-income families. She is a Co-Principal Investigator of Children's HealthWatch and founder of the Witnesses to Hunger project.

References

Alaimo, K., C.M. Olson and E.A. Frongillo, Jr. (2002). Family food insufficiency is associated with dysthymia and suicidal symptoms in adolescents: Results from NHANES III. Journal of Nutrition. 132:719-725.

Alaimo, K.. (2000). Consequences of food insufficiency for American children. Dissertation Abstracts International: Section B: The Sciences & Engineering. Print 61 (6-B).

Casey, P., S. Goolsby, C. Berkowitz, D. Frank, J. Cook, D. Cutts, M.M. Black, N. Zaldivar, S. Levenson, T. Heeren, and A. Meyers. (2004). Maternal depression, changing public assistance, food security, and child health status. Pediatrics. 113(2):298-304.

Catalani, C. and M. Minkler. (2010). Photovoice: a review of the literature in health and public health. Health Education & Behavior. 37(3):424.

Chilton, M., J. Rabinowich, C. Council and J. Breaux. (2009). Witnesses to Hunger: participation though photovoice to ensure the right to food. Health and Human Rights. 11(1):73-86.

Coleman-Jensen, A., M. Nord, M. Andrews and S. Carlson. (2011). Household Food Security in the United States in 2010. ERR-125, U.S. Dept. of Agriculture, Econ. Res. Serv.

Cook, J.T., D.A. Frank, C. Berkowitz, M.M. Black, P.H. Casey, D.B. Cutts, A.F. Meyers, N. Zaldivar, A. Skalicky, S. Levenson, T. Heeren, and M. Nord. (2004). Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 134(6):1432-8.

Frongillo, E.A., D.F. Jyoti, and S.J. Jones. (2006). Food Stamp Program participation is associated with better academic learning among school children. J Nutr. 136(4):1077-80.

Rose-Jacobs, R., M.M. Black, P.H. Casey, J.T. Cook, D.B. Cutts, M. Chilton, T. Heeren, S.M. Levenson, A.F. Meyers, and D.A. Frank. (2008). Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 121(1):65-72.

Skalicky, A., A.F. Meyers, W.G. Adams, Z. Yang, J.T. Cook, and D.A. Frank. (2006). Child Food Insecurity and Iron-Deficiency Anemia in Low-Income Infants and Toddlers in the United States. Matern Child Health J. 10(2).

Wang, C., and M.A. Burris. (1997). Photovoice: concept, methodology, and use for participatory needs assessment. Health Educ Behav. 24(3):369-87.

On a normal day in Philadelphia, about 4,000 people are homeless, and over the course of a year, more than 3,500 young people resort to sleeping in an emergency shelter (Children’s Work Group 2010). Public health researchers have clearly documented a range of adverse health effects associated with housing insecurity and homelessness, including threats to mental, physical and social wellbeing (Bassuk 1997; Rouse 2009; Weinreb 1998; Ma 2008; Perlman 2010).

The artists and educators of Philadelphia’s Mural Arts Program (MAP) saw first-hand how this social problem affected the high-risk youth they serve in art education and life skills training programs. Over and over again, the MAP team recognized that their youth got into trouble—dropping out of school, not showing up for work, getting involved with the juvenile justice system—when their access to stable housing was threatened.

Committed to improving the lives of young people facing housing insecurity, MAP developed the arts and advocacy initiative: A Place to Call Home. A multidisciplinary team of artists, researchers, public servants, community members, the press, a real estate developer and, most importantly, 48 high-risk youth participating in Mural Arts programs, came together to create a mission statement that would define the path ahead:

Our mission is to engage and empower Philadelphia youth in order to understand how home, as they define it, contributes to—or takes from—their sense of wellbeing. In addition, we will increase awareness of how Philadelphia’s socioeconomic diversity contributes to the health and life chances of the city’s residents. These goals will be achieved through photo-documentation, storytelling, and art-making.

Over the course of six months, the MAP project team acted together on this mission, under the direction of Shari Hersh and lead artists Ernel Martinez, Shira Walinsky and Damon Reaves. The team adopted a systematic approach that included photo-documentation and photo-elicitation interviewing to organize this expansive collaboration (Cannuscio 2009). The first step was to photographically document housing conditions along Spruce Street, a major corridor cutting through the city, from Cobbs Creek to the Delaware River, adhering to a strict protocol. These photos generated team discussions regarding how housing conditions vary across the city’s socioeconomic gradient. Second, we gave cameras to the 48 high-risk youth and asked them to explore and document what home means to them from their “insider” perspective. Third, a group of researchers and newly trained artists and undergraduate students interviewed the youths, using each young person’s own insider images of home as the basis for photo-elicitation interviews. The interviews focused on the young people’s highly personal experiences of home and, in some cases, homelessness (Cannuscio 2012).


A Public Art Installation in Mantua

In the photo-elicitation interviews, the young people were forthcoming about the insecurity of their home lives and how they frequently relied on temporary solutions, such as staying with extended family or friends, or at shelters, in lieu of stable housing. The stories revealed in photo-elicitation interviews were the genesis of a range of multi-media art installations on and around Melon Street in Philadelphia’s Mantua neighborhood. There, a developer from West Philadelphia Real Estate donated an abandoned row home that the team revived and turned into an Art House—filled outside and in with art inspired by the young people’s stories about the meaning of home. In addition to art, the house also provided practical information and resources regarding housing, jobs, education and social services, for the benefit of the young people themselves as well as the local community and visitors to the Art House.

Photo by Steve Weinik
Photo 1. An abandoned row home on Melon Street was transformed from a drug house into an Art House containing multi-media installations based on young people’s stories of housing insecurity and homelessness.

The Art House itself became part of a block-long mural on Melon Street, envisioned and created by artist Ernel Martinez, who engaged neighbors in intense conversation and negotiation regarding how their individual homes and their block should be visually transformed. This process, which Martinez saw as an important part of the art itself, built trust among neighbors in a place where trust had long been undermined by the challenges of poverty, violence and an active local drug trade. Through his intensive efforts and communication, Martinez successfully integrated almost every house on the block into his artwork; now the mural stands as a visual symbol of the connections among neighbors. Martinez rejected the idea of an iconic mural for this project, instead developing a conceptual work that emphasized continuity and community while retaining the individual identity of each home.

Photo by Steve Weinik
Photo 2. Melon Street before its transformation during the Mural Arts Program’s installation in A Place to Call Home.

Photo by Steve Weinik
Photo 3. Melon Street after artists, neighbors, students and volunteers worked together to create the block-long mural designed and directed by artist Ernel Martinez.

Artist Shira Walinsky emblazoned nearby row homes with a series of vivid murals incorporating symbols of security, shelter and comfort—themes that frequently emerged during the project’s photo-elicitation interviews. The strong colors and bold images Walinsky chose for these works conveyed the pivotal importance of domestic life. Walinsky’s murals encouraged the local community to initiate conversations about the meaning of home. She augmented her large-scale works with smaller wheat-pasted murals—signs that called up the universal need for heat, food, water and shelter. Together, these works formed a path to the Art House and offered repeated opportunities for neighbors to reflect on home as an essential component of human dignity.

Photo by Steve Weinik
Photo 4. Artist Shira Walinsky created a visual path to the Art House on Melon Street with a series of murals emphasizing the central importance of housing security to individuals, families and the Philadelphia community.

Photo by Steve Weinik
Photo 5. Shira Walinsky’s small-scale murals and wheat-pasted prints offered bold visual reminders of our community’s most essential needs.

These themes resounded within the Art House, where Martinez installed furniture literally crafted out of the transcribed interviews with the high-risk youth. A dining table, chairs, wallpaper and dinnerware were all sculpted from paper, conveying the actual stories shared by the youth and also metaphorically underscoring the insecurity of home for many of these youth. While the dining set appeared sturdy and inviting, in reality it was highly fragile. In adjoining rooms, stop-motion animation by Damon Reaves wove together images of a classic Philadelphia row house, including its active interior life, with audio recordings from youth interviews. These animations contrasted images of domestic comfort with the struggles that youth encounter as they attempt to identify secure housing—often for themselves and for family members who depend on them for support. Upstairs, prints and an audio mural by WHYY’s Elizabeth Perez Luna offered the visitor an immersion in the life experiences of youth struggling to find a place to call home (Perez-Luna 2011).


What Elements of the Project Worked?

The team reflected on what elements of the project advanced the mission of “engaging and empowering Philadelphia youth in order to understand how home, as they define it, contributes to—or takes from—their sense of wellbeing.”

The project had a clear structure and applied a tested method. This project was structured to include documentary photography, photo-elicitation interviewing, community engagement and art-making. The approach offered a strong model (Cannuscio 2009) that allowed artists, researchers, a real estate developer, public servants and concerned citizens to connect with and hear the housing-related concerns of high-risk youth and the Mantua community. The method was disciplined and brought order and a sense of direction and purpose to the project, so that the group could move together toward the goal of hearing the young people’s stories and then amplifying their voices through public art.

The issue of housing resonated for the young people, and they stayed involved in the project for its duration. The youth were deeply engaged in the storytelling and art-making. They were mentored closely by accomplished artists and educators throughout the process. The youth spoke passionately over several months about their concerns regarding housing and home, their own wellbeing, and the health of their peers. Through their commitment to this project, the youth demonstrated that these issues are central to their identity and the sense of possibility in their lives. They used the project as an opportunity to connect with local housing resources and with concerned adults. The MAP team fostered youth commitment by engaging and empowering them at every step of the project. Participants’ photographs guided their photo-elicitation interviews, and the themes that emerged from their interviews inspired Martinez, Walinsky and Reaves’ art. Participants helped edit their own interview transcripts. Some young people even participated in the artistic process by collaborating with MAP artists, helping transform abstract ideas about home and security into art. The artists, researchers, and team members believed that: 1) the young people felt truly heard during the course of the project; and 2) engaging the youth through active conversation and close listening prepared them to contribute meaningfully to the team’s efforts on Melon Street.

The issue of home is universal and spoke to all members of the project team. Because the issue of home is of universal importance, every contributor had a valuable perspective and a personal history to add. This fueled conversations and energized the artists as they transformed wide-ranging stories into inspired multi-media installations that resonated in the community.

Artists, students, staff and research team members developed new skills that allowed for effective engagement. The project team, which included a group of approximately two dozen undergraduate students from Jane Golden and Shira Walinsky’s community murals class at the University of Pennsylvania, developed new skills in photo-elicitation interviewing and the use of human stories in the creation of public art. Artists, administrators, and assistants were also trained in interview methods. These students—and the whole team—found a meaningful way to step outside the classroom or the everyday structures of work in order to engage with the local community and to reflect upon the experiences of the 48 youth involved.

Change was sparked in a neighborhood that has long struggled with a range of social and economic issues. The changes in the community were both metaphorical and physical. Community members were given a voice, and were given a say in the physical transformation of their neighborhood; they initiated new relationships and found a renewed sense of connection to their own homes and block. Mural Arts was well-positioned to bring diverse city resources to the block, which demonstrated to the residents of Melon Street that the city can serve them, even as they engage in change to help themselves.

Social services were delivered in a vibrant setting that worked to attract participation and reduce stigma. The project created awareness about the importance of housing, and about pervasive community concerns regarding housing insecurity. Stigma and shame were reduced through sustained dialogue across the project team, in interview dyads, and in public forums—including the well-attended dedication of the Art House and Melon Street mural. The project inspired many of the youth involved to reach out for help. Youth participating in the project encouraged their peers to get involved as well, and to seek help and services for their housing needs. Residents of Melon Street and visitors to the Art House were also invited to share in the information and social service resources provided through the project.

Public life was rekindled on Melon Street. When the team first started on the street, there were abundant signs that home was a struggle, a burden and a source of concern. Facades were fading and in some cases crumbling; windows were broken; lots were vacant and unkempt. And most importantly, the street was silent and deserted, with very few people venturing outside into the shared community spaces. The team hoped that, as a first step toward community change, the physical space would be transformed. As artist Ernel Martinez reflected on the project, he commented that sometimes the art is in the mural—in its colors and forms—and sometimes the art is in the process—in the coming together of once-distant neighbors to revitalize the space they share and call home. This latter art—fostered in large part by the dedication of the lead artists themselves—was evident on an active community paint day, with residents across generations participating. It was also apparent when the exhibit opened: There was life on Melon Street, with hundreds of people—including all of the 48 originally involved high-risk youth—coming together to witness the change. They were there to join their voices together regarding the meaning and challenges of housing and homelessness.

Photo by Steve Weinik
Photo 6. The public space was renewed, socially and physically, on a community paint day on Melon Street.


What is Next?

The project team is convinced that this work has only just begun. In the future, the team will continue working to understand local residents’ concerns regarding housing insecurity and the meaning of home. One plan under consideration is to select some of the 48 young people who were originally interviewed for the project so that they can assist in interviewing additional community residents. The team also hopes that the Art House concept will be revived to provide an ongoing “third place” where community residents can gather to learn, generate art and nurture social relationships among neighbors. In addition, the Art House will serve to connect residents of the immediate neighborhood and the broader Philadelphia community. Though this step is in the planning phase, the concept is to solicit community-generated suggestions for how the Art House can best be used to showcase and develop the talents and skills (artistic and otherwise) of the community.  The artists from this project described a strong desire to foster the assets of the neighborhood and its youth, particularly through efforts focused on education, economic development and job readiness. For example, the Art House may be used as a location for workshops, to provide solid skills and opportunities for the youth of the neighborhood. Potential workshops include college preparatory work, or helping youth find internships.

In sum, this project brought together a diverse project team to address the centrality of home in all lives, including the lives of high-risk youth. The team encountered young people and a community eager to discuss issues of housing insecurity and homelessness. A few months after wrapping up the first stage of A Place to Call Home, the project team received a note from the block captain of Melon Street, the project site in Philadelphia's Mantua neighborhood. She wanted to tell the team about the changes she saw afoot in her community. People were sprucing up their homes, paying attention to upkeep, and even buying new windows and doors. These seemingly mundane tasks were interpreted as a watershed by the project team, given the daunting challenges of Melon Street and the surrounding community. Residents, young people, artists and researchers have seen that change is possible. Much work remains, however, and more can be accomplished if all of these groups continue to work together to combine art, research and advocacy as tools to advance the mission of A Place to Call Home.

Carolyn Cannuscio is a social epidemiologist and a Core Investigator at the Center for Health Equity Research and Promotion at the Philadelphia VA Medical Center.  She is also an Assistant Professor in the Department of Family Medicine and Community Health at the University of Pennsylvania Perelman School of Medicine.

Eva Bugos is with the Mixed Methods Research Laboratory and the Center for Public Health Initiatives, University of Pennsylvania. She is an undergraduate at the University of Pittsburgh.

Katie Kellom graduated from Bryn Mawr College in 2009 with a degree in Psychology. She currently works as a Research Assistant for the Mixed Methods Research Lab pursuing her interests in health behavior, community structures, and social deviance.

Shimrit Keddem is the manager of the Mixed Methods Research Lab at the University of Pennsylvania School of Medicine. She provides managerial and technical support and expertise on qualitative and mixed-methods research to faculty, staff and trainees.   Shimrit has a background in psychology and a Masters in Urban Spatial Analysis from the University of Pennsylvania.

Shari Hersh serves as Mural Arts' Senior Project Manager. Building on 13 years of experience at the organization, she is currently responsible for project development and management with a focus on socially engaged projects that highlight youth involvement and utilize collaborations with institutional and community partners.

Jane Golden serves as Mural Arts' Executive Director and has overseen the organization's grwoth from a small city agency into the nation's largest mural program and a model for community development. Under Golden's direction, Mural Arts has created over 3,500 landmark works of public art through innovative collaborations with communities, grassroots organizations, city agencies, schools and philanthropists.

Elizabeth FitzGerald is a research coordinator at the University of Pennsylvania. She has expertise in visual research methods.

References

Bassuk EL, Weinreb LF, Dawson R, Perloff JN, Buckner JC. Determinants of behavior in homeless and low-income housed preschool children. Pediatrics 1997;100(1):92-100.

Cannuscio CC, Weiss EE, Fruchtman H, Schroeder J, Weiner J, Asch DA. Visual epidemiology: Photographs as tools for probing street-level etiologies. Social Science & Medicine 2009;69(4):553-564.

Cannuscio C, Bugos E, Hersh S, Asch DA, Weiss EE. Using ART to AMPLIFY Youth Voices on Housing Insecurity. American Journal of Public Health 2012;102(1):10-12.

Children’s Work Group. (2010, August 26). Philadelphia Children and Youth Experiencing Homelessness. Available at https://www.pccy.org/userfiles/file/ChildWelfare/HomelessChildrenReport2010.pdf.

Ma CT, Gee L, Kushel MB. Associations between housing instability and food insecurity with health care access in low-income children. Ambulatory Pediatrics 2008;8(1):50-57.

Perez-Luna, E. (2011, June 17). How teens see ‘home,’ even when they lack one. NewsWorks. Available at http://www.newsworks.org/index.php/a-place-to-call-home/item/21647-how-teens-see-home-even-when-they-lack-one.

Perlman S, Fantuzzo J. Timing and influence of early experiences of child maltreatment and homelessness on children's educational well-being. Children and Youth Services Review 2010;32(6):874-883.

Rouse HL, Fantuzzo JW. Multiple risks and educational well being: A population-based investigation of threats to early school success. Early Childhood Research Quarterly 2009;24(1):1-14.

Weinreb L, Goldberg R, Bassuk E, Perloff J. Determinants of health and service use patterns in homeless and low-income housed children. Pediatrics 1998;102(3):554-562.

InterAct Theatre Company is a theatre for today’s world, dedicated to producing new and contemporary plays that explore the social, political and cultural issues of our time. The company sees itself as a kind of “public square,” utilizing theatre as a tool to promote civic engagement and stimulate dialogue around the most pressing, complex and compelling issues we face in contemporary society.

In its 24-year history the company has produced numerous plays that explicitly examine issues pertaining to public health, including The Elephant Man by Bernard Pomerance (1989), the tragic true story of John Merrick’s challenges as a creative, British dreamer afflicted with the rare, grotesque and debilitating disease neurofibromatosis; the world premiere of Under Yelena by Buffy Sedlachek (1998), about two Soviet scientists charged with researching the impact of radiation at the Chernobyl nuclear power plant after the infamous meltdown in 1986; the world premiere of Man Measures Man by David Robson (2001), the story of two American Jewish doctors who volunteer to help refugees during the Kosovo war in the mid-1990s; Going to St. Ives by Lee Blessing (2002), about the mother of a brutal Central African dictator (à la Idi Amin) who visits a British eye doctor in London, hoping to solicit poison with which to kill her son for her country’s greater good; Rosemary by Jim O’Connor (2003), about the iconic Kennedy family’s sequestering of the mentally disabled oldest sister, Rosemary; and Blue/Orange by Joe Penhall (2005), the story of two British psychiatrists who battle over the diagnosis and treatment of a schizophrenic man who believes himself to be the son of Idi Amin. Many other InterAct plays have explored ideas and issues more peripherally related to public health, such as poverty, homelessness, rape, adoption, sexuality, violence, war and incarceration. 

Two of InterAct’s productions stand out as being particularly impactful with regard to public health, going well beyond the normal theatre-going experience of seeing a thought-provoking play.  

In January/February of 1996, InterAct produced the Philadelphia premiere of Lonely Planet by Steven Dietz. Inspired, in theatrical metaphor, by Ionesco’s The Chairs, and in content by the AIDS epidemic, Lonely Planet is a charming, funny and ultimately moving play about two gay friends: Carl, a flamboyant man with an unusually vivid imagination and multiple, ever-changing occupations; and Jody, a cautious and thoughtful man who has insulated himself in his map store, afraid to venture out into the world and get tested for AIDS. As the play evolves, Carl shows up in the store time and again toting increasing numbers of chairs, and delivering outrageous yarns, both of which irritate Jody. That is, until we (and Jody) learn that the chairs belong to friends of theirs who have died of AIDS, and Carl is trying to memorialize them in some meaningful way. As the map store steadily fills with chairs, Carl gets Jody to finally confront his fears and get tested. Jody learns that he is HIV-negative. But upon returning to his store in the final scene, Jody finds Carl's favorite chair sitting in the store.

Following a decade of AIDS-inspired plays, Lonely Planet was unusual in that it never mentioned the disease by name, and it was explicitly and exclusively about friendship (as opposed to romantic and/or sexual relationships).

InterAct produced Lonely Planet at a time when AIDS was firmly rooted in the public’s consciousness, and early on in its planning InterAct sought to reach out to the community in a unique way to maximize the impact of the production. One of the play’s requirements was to fill up a store with dozens and dozens of unique chairs. So, through partnerships with a number of AIDS and gay-related organizations we invited people to donate chairs that belonged to loved ones who had died of AIDS to the production. The response was overwhelming. We received over 50 donations of every kind of chair imaginable: kitchen chairs, armchairs, dining room chairs, porch chairs, church seats, love seats, ladderbacks, even a toddler's high chair. Donors were invited to come see the show and experience their loved ones' chairs on stage in a living memorial, just as the play was intended. At every single performance there was at least one, if not several, patrons who would involuntarily gasp or cry or point when their friend’s chair appeared, imbuing the theatre-going experience with extraordinarily personal meaning for some, and enhanced awareness for all.

In a very different way, InterAct achieved significant community impact with its world premiere production of Reinventing Eden by Seth Rozin in March/April of 2006. Reinventing Eden revolves around an eminent geneticist, Jonas Tuttle, whose cutting edge research in biotechnology has rendered him a leader in his field for more than two decades. His wife, Lizzie, has sacrificed her own career goals to care for their oldest son, Pauly, who suffers from an inherited mental disability. Jason, the younger son, returns from a volunteer social work mission in Africa to celebrate his father’s winning a prestigious prize. But upon Jason’s arrival, Jonas reveals that he is being investigated for an allegedly unauthorized gene therapy experiment he conducted on human embryos 25 years earlier. Through the investigation, as well as scenes from Jonas and Lizzie’s past, we (and Jason) learn that the experiment-in-question was conducted on Jason, in utero, to prevent him from suffering the same affliction as his brother. This revelation rocks Jason’s foundation, catapulting him into a crisis of identity and an abyss of “survivor” guilt. Jonas must now grapple with the public and familial fallout of his actions, while remaining adamant that scientific inquiry must move forward at its own pace.  

This taut family drama explored the personal and political implications of genetic engineering, an activity which, while far less controversial than cloning, will prove to be much more relevant to virtually everyone in the industrialized world in the next couple of generations.  

In conjunction with the world premiere production of Reinventing Eden, InterAct hosted a free, public panel discussion entitled The Implications of Genetic Engineering, which was attended by over 100 people. The panel was moderated by Art Caplan, Director of the University of Pennsylvania Center for Bioethics, and featured an impressive set of discussants: James Wilson (Professor of Pathology and Laboratory Medicine at the University of Pennsylvania), who is best known for a pioneering yet tragic gene therapy experiment, and who participated as an active consultant on the writing of the play; Father Tadeusz Pacholczyk (Education Director of the National Catholic Bioethics Center); Paul Rozin (Professor of Psychology at the University of Pennsylvania); Lee Silver (Professor of Molecular Biology at Princeton University and author of the book Remaking Eden); and playwright Seth Rozin. The two-hour event engaged the largely lay public audience in a lively, high-level discussion of the ethical, political, psychological and theological implications of gene therapy.

Perhaps the most compelling comment of the afternoon came from Dr. Wilson, who had attended two performances of Reinventing Eden. He relayed his revelatory experience witnessing the personal side of the science he deals with so routinely on a clinical level, and how many of the myriad familial, personal and identity conflicts presented in the play had never occurred to him. And this comment, in a nutshell, encapsulates the ultimate value of InterAct’s oeuvre: revealing the often-unanticipated or difficult to imagine human expressions of, and responses to, our continually evolving world.

Seth Rozin is the founder and Producing Artistic Director of InterAct Theatre Company in Philadelphia, as well as a freelance director and playwright. He is the recipient of the 1999 Barrymore Award for Outstanding Direction of a Play, two Playwriting Fellowships from the Pennsylvania Council on the Arts, and the National New Play Network’s 2007 Smith Prize, as well as being twice named Best Director by the Philadelphia Inquirer.

Background

Since the mid-1970s, millions of immigrants and refugees have come to the United States from Southeast Asia (U.S. Census Bureau 2007). Unlike some of the more established segments of the American population, these new Americans suffer from higher poverty, lower education and numerous health-related disparities. The challenges faced by these communities can be amplified further by low health literacy, limited English proficiency, real and perceived discrimination, and a lack of community infrastructure to support their diverse needs.

Over the last decade, the Asian American population grew by 43 percent nationally, while the White population shrank (U.S. Census Bureau,2011a).  Between 2000 and 2010, the population of Philadelphia grew by 0.9 percent, the first decennial gain for the city since the 1940-1950 period (U.S. Census Bureau 2011b). This was driven in large part by the influx of immigrants and other minorities.

The Southeast Asian Mutual Assistance Associations Coalition, Inc. (SEAMAAC), a Philadelphia-based nonprofit organization, has been serving refugees, asylees and other immigrants in the region for nearly three decades. Among SEAMAAC’s community activities are programs related to citizenship, English language education, youth and elderly outreach, social services and health promotion. Frustrated by the lack of reliable data that accurately reflected the true health status of Southeast Asians in the Philadelphia region, the staff of SEAMAAC partnered in 2007 with public health experts at the University of Pennsylvania and Drexel University to embark on the process of collecting community-based health data for the communities they served (the research team was later joined by a researcher from Thomas Jefferson University, as well). These data pointed to a number of important health disparities that to date had not been systematically reported for this underserved community (Nguyen et al. 2011). However, it was clear that data alone would not lead to sustainable improvements in the health of their communities.

The use of personal narratives was proposed as a potential avenue for bringing about community-wide behavior change to support healthy lifestyles. This idea is supported by the fact that, unlike many European American traditions that may emphasize the use of stories for entertainment purposes, Asian families may be more likely to use storytelling for the purpose of education and to reinforce social norms (Miller, Wiley, Fung, & Liang 1997). Hence, the creation of an infrastructure that supports health-related storytelling and involves residents, community organizations, and local media carries great potential (Ball-Rokeach, Kim & Matei 2001).


Coalition Building

In autumn 2007, a team including the University of Pennsylvania Asian Health Initiatives, SEAMAAC, WHYY (the local public broadcasting station), Thomas Jefferson University and Temple University’s Project SHINE successfully obtained funding for a video storytelling project using the newly collected data as a springboard for community action and engagement of Southeast Asian immigrant elders. This partnership used a community-based participatory research (CBPR) approach (Viswanathan et al. 2004) and included community stakeholders, experts in video production (WHYY), experts in immigrant community outreach (SEAMAAC), and experts in CBPR, primary care medicine, program evaluation, and adult learning (academic partners). The project’s logic model is shown in Figure 1.

At the core of the new project was an Elders Council comprised of members of the Laotian and Vietnamese immigrant communities. The leadership at SEAMAAC envisioned this Council as a means by which members of the community could reclaim their traditional status of leader and advisor as they grew older. In Asia, younger adults would often turn to their elders for guidance, yet in the United States, the opinions and wisdom of elders were often neglected and forgotten.

The Elders Council grew out of a weekly elders breakfast gathering hosted by SEAMAAC, where older immigrants had been gathering every week to meet new friends, enjoy rice porridge and noodles, and play traditional board games. When a small group of attendees approached the leadership of SEAMAAC to see if something could be done about safety and other conditions in their neighborhood, it became apparent that some of the elders had an interest in civic engagement, yet few avenues to act upon that interest.

The Elders Council included members of both the Laotian and Vietnamese immigrant communities of Philadelphia, largely because these were the communities represented at the weekly breakfast gatherings. The size of the Council started at eight members (both men and women), but the total membership fluctuated over time as some members moved away or became busy with family responsibilities, and other members joined to take their place.


A Multiethnic and Multilingual Council

Some of the Elders Council members were able to speak English, and a few were bilingual in Lao and Vietnamese. However, the majority of members were monolingual in the languages of their countries of origin. Despite these linguistic differences, the Council members had a shared experience as immigrants and refugees, and they had become comfortable with each other through the weekly breakfast gatherings. As a result, the elders were quite clear that they did not wish to have a separate Laotian Council and Vietnamese Council. They saw themselves as a single unit, with shared goals.

The realities of working with a multiethnic and multilingual community advisory council meant that planning meetings and training sessions usually required much more time than standard meetings. Although SEAMAAC had outreach workers who could speak Lao and Vietnamese, they had no single outreach worker who was fluent in both languages. English, therefore, was used as a common language with which to facilitate the language interpretation. Moreover, some of the academic collaborators could speak neither Lao nor Vietnamese, and they also relied on English. Consequently, those who attended Elders Council meetings quickly learned that they needed to speak in brief phrases to allow each sentence to be translated into two other languages before a conversation could proceed. This was time-consuming, but the Elders Council members and other collaborators showed tremendous patience with the process, because everyone believed in the value of this endeavor.

Linguistic concerns were not the only challenge, however. The Vietnamese elders had the benefit of a more functional educational system in their homeland when they were growing up than did the Laotian elders, and the Vietnamese American community was more established in Philadelphia than was the Laotian American community. As a result, the Vietnamese members of the Elders Council were more vocal and larger in number. Overall, there were no major disagreements, but it was nonetheless important to ensure that the experiences, needs, and concerns of the Laotian elders were not overlooked during the Council discussions.


Setting the Course

The Elders Council was charged with the task of reviewing reports from the community health data described earlier, and combining that information with their own personal experiences in the community, in order to choose health topics that would become the focus of the collaborative project. The data reports were presented in a concise fashion, with the understanding that the community members were not scientists and had varied levels of educational attainment.

After reviewing the data and having a group discussion, the Elders Council decided that the project should focus on high blood pressure and on doctor-patient communication.


Video Training

The elders received basic training from the Learning Lab at WHYY (now known as the Hamilton Public Media Commons), a digital media lab set up to teach community members how to create their own digital media. The Learning Lab had worked with some older community members in the past, but their experience was primarily with youth, and this was the first time they had worked with non-English speaking Asian elders. It was a growing process for everyone involved, but the elders were enthusiastic and eager to gain experience with the camera equipment. Although the elders were highly motivated, it became clear that there would be limits to how much they would be able to perform with regard to the more complicated technology, given the rate at which training could proceed and the timeline of the grant-funded project. Tasks such as lighting setup, sound checks, digital editing, and subtitling were simply beyond the scope of what could be done by the elders given the timeline of the project.


Intergenerational Engagement


The challenges mentioned above provided the team with an unexpected opportunity to bring an intergenerational component to the project that had not been planned at the beginning. Undergraduate students and graduate interns from the Southeast Asian communities were able join the project, serving as on-set assistants, ad hoc interpreters, and video editors. This type of intergenerational collaboration was enriching for both the young people and the elders alike.


Community Storytelling

The key component of the project was, of course, the stories that were being told. For example, one gentleman told of his experiences with high blood pressure, a condition that at first he took lightly; he did not take his medicine consistently, until one day he felt ill while driving and had a car accident. The paramedics found his blood pressure to be very high when they arrived at the scene of the accident; this was a wake-up call for him. Another man spoke about the trouble he had trying to receive linguistically appropriate healthcare services, while one woman spoke about strategies she used to make sure that she kept her hypertension under control. These stories came directly from the elders, or from other community members recruited by the elders or by SEAMAAC staff. The stories were edited and woven into an interactive workshop curriculum designed for adult learners of all ages (not just the elderly).


“But Don’t Call Me A Leader”

Humility is a key component of Asian values (Kim, Li, & Ng, 2005). As such, the Elders Council members were rather reluctant to be called “leaders”. Although several of them had a long history of volunteering at religious and social organizations in their communities, they were somewhat hesitant to be recognized as leaders of their communities when they became involved in the Elders Council. Nonetheless, they demonstrated a great deal of leadership skill that blossomed even more as their involvement in the project continued.

The volunteers on the Elders Council did more than just set the original direction of the project. They reviewed and edited the interview guides used to prompt community members to share their experiences during filming sessions. They watched the raw video footage and offered recommendations about whether sufficient material had been recorded, or whether additional questions should be added to broaden the scope of responses being collected. They pilot tested the educational workshop materials, and some of them served as workshop helpers when educational sessions were presented by the SEAMAAC outreach workers.

To some degree, the elders themselves were rather surprised at how well the process worked. Toward the end of the workshop development process, one of the elders admitted that he was rather skeptical about the idea of doing a media project such as this; however, when the videos were completed and fully integrated with the new workshop curriculum, he could see how valuable and effective this could be.


Lessons Learned

The partnership process described in this paper led to the realization of a number of points that could be useful to others who might wish to implement a similar model of community engagement. Following are a few lessons learned:

  1. When doing a participatory project involving multiple languages, do not underestimate the amount of time that will be required.
  2. When engaging non-English speaking immigrant elders in a video project, not all steps in the production process can be feasibly done by the elders, even with formal training (for example, video editing, subtitling, etc.).
  3. Video editing for non-English language footage is a challenge when production experts do not understand the language. However, it can be accomplished with adequate multilingual volunteer support (and training of the volunteers).
  4. When working with multiple ethnicities, be aware of any imbalance due to differences in representation from different subgroups, as well as differences in baseline experience or education that might result in one subgroup having a stronger voice than another.
  5. Immigrant elders (even those with limited English proficiency) welcome the chance to be engaged in non-profit work with their communities, particularly if appropriate opportunities and linguistic resources are provided.

Acknowledgements and Disclosures

This project was funded by grant from New Routes to Community Health, a national program of the Robert Wood Johnson Foundation and administered by the Benton Foundation (PI: G.T. Nguyen). After this project was initiated, authors Giang Nguyen and Elaine Yuen were asked to serve on the Board of Directors of SEAMAAC; at the time of this writing, both authors continue to serve in this capacity as volunteer board members. Some of the material in this paper was presented in 2010 as part of “Creative Action: The Arts in Public Health,” a seminar series hosted by the Center for Public Health Initiatives of the University of Pennsylvania, Philadelphia, PA.

Giang T. Nguyen, MD, MPH, MSCE is an Assistant Professor of Family Medicine and Community Health at the University of Pennsylvania, where he leads the Penn Asian Health Initiatives. His research focuses on Asian immigrant health, community based participatory research, and cancer prevention and screening. In addition to seeing patients, he also teaches medical students, family medicine residents, and public health students.

Ethan T. Nguyen, MPH is a health researcher at the University of Pennsylvania. His work focuses on social media and disease prevention, translational cancer care, and health care access in immigrant communities.

Elaine J. Yuen, PhD, MBA is an Adjunct Associate Professor in the Jefferson School of Population Health at the Thomas Jefferson University.  Her research interests include healthy aging, diversity, cultural competency and access to care, and community-based participatory research. As a result of her research activities, Dr. Yuen has a long record of successful collaboration with community groups, physicians and other health care providers in articulating research aims, as well as developing and executing research methodologies that will meet these goals. Dr. Yuen also teaches the Cultural Humility and Competency, Research Methods, and Geographic Information Systems courses at Jefferson.

Craig Santoro is Director of Media Instruction at WHYY Public Media. Craig joined WHYY in 2002 and shortly thereafter started the station’s first youth media program. Since then, he has created and managed ongoing after-school documentary workshops for Philadelphia teenagers and partnered with community centers to hold video production classes for teens who have dropped out of school. He’s developed award-winning video summer camps, partnered with numerous schools to train teachers to use video in their classrooms and created video learning experiences for nonprofit organizations, higher education institutions and learners of all ages.

Tina Kluetmeier, MSEd is an education consultant with over 20 years of experience teaching ESL, developing programs and providing training and technical assistance to community-based organizations and universities in the U.S. and abroad. Previously, Tina directed Project SHINE, a national civic engagement initiative coordinated out of Temple University’s Intergenerational Center. SHINE builds partnerships that bring college students and older immigrants together to serve their communities

Thoai Nguyen is a first generation Vietnamese refugee whose family immigrated to the United States.  He is a long time community organizer and advocate who has worked for peace and social justice in many communities throughout Africa, Asia, Eastern Europe, and North America. Thoai is the current CEO of SEAMAAC, Inc. whose mission is to serve and advocate for refugees and immigrants in the Greater Philadelphia area. 

References

Ball-Rokeach, S. J., Kim, Y.-C., & Matei, S. (2001). Storytelling Neighborhood: Paths to Belonging in Diverse Urban Environments. Communication Research, 28(4), 392-428.

Kim, B. S. K., Li, L. C., & Ng, G. F. (2005). The Asian American Values Scale — Multidimensional: Development, Reliability, and Validity. Cultural Diversity and Ethnic Minority Psychology, 11(3), 187–201.

Miller, P. J., Wiley, A. R., Fung, H., & Liang, C. H. (1997). Personal storytelling as a medium of socialization in Chinese and American families. Child Development, 68(3), 557-568.

Nguyen, G. T., Yuen, E. J., Hsu, L., Kue, K. N., & Nguyen, T. (2011). Community-partnered health surveys of Asian Americans: Public health and policy implications. Journal of Health Care for the Poor and Underserved, 22, 1101-1114.

U.S. Census Bureau. (2011a). Overview of Race and Hispanic Origin: 2010. 2010 Census Briefs(C2010BR-02).

U.S. Census Bureau. (2011b). Population Distribution and Change: 2000 to 2010. 2010 Census Briefs(C2010BR-01).

US Census Bureau. (2007). The American Community - Asians: 2004 (No. US Census ACS-05)o. Document Number)

Viswanathan, M., Ammerman, A., Eng, E., Gartlehner, G., Lohr, K. N., Griffith, D., et al. (2004). Community-based participatory research: Assessing the evidence (No. AHRQ Publication No. 04–E022-2). Rockville MD: AHRQo. Document Number)

In the fall of 1994 I befriended a community of some two dozen heroin injectors and crack smokers surviving under the overpasses of a tangle of freeways six blocks from where I lived in San Francisco. The full force of the Reagan-era cutbacks from the 1980s had trickled down to the street, shredding the already rachitic U.S. welfare safety-net. Inner-cities were gentrifying (especially those linked to the epicenters of global finance capital such as San Francisco). The former skid row habitat for the unstable urban poor—cheap single-residency hotels—was being converted into multi-million dollar condominiums. Urban police forces had not yet systematized, routinized and replicated their zero-tolerance enforcement, harassment/incarceration dragnets (Wacquant 2009) and homelessness, consequently, was at its most visible. Bourgeois residents like me could not walk down a block or drive up a freeway entrance ramp in downtown San Francisco without being solicited for spare change. I obtained a National Institutes of Health HIV prevention grant and for the next 12 years, together with a photographer/anthropologist collaborator Jeff Schonberg and several additional ethnographic team members, we followed the social network of homeless addicts surviving in my neighborhood, documenting the unhealthy effects of indigence and substance abuse.


Our Punitive Era

This span of years from 1994 to 2007 was a terrible time for the poor in the United States and throughout much of the rest of the world: 1) The punitive version of neoliberalism was consolidating in the United States and was achieving hegemony—even if unevenly (Harvey 2005)—across much of the globe. 2) The U.S. War on Terror was inaugurated with great bloodshed, routinizing the curtailment of civil rights. 3) The recession of 2007-2009 accelerated the ongoing public subsidy of high finance, public service cutbacks, reinforcing the bulwark for the long-term rise in income inequality that has been occurring since the 1970s (McCall and Percheski). 

Change in Violent and Property Crime, and Inmate and Total Population, 1960-2008

Source: Authors' analysis of FBI and BJS data, Center for Economic Policy Research 2010

Public health and social welfare programs in the United States have been overshadowed by state investment in incarceration despite decreasing or stable crime rates. Imprisonment has become the most aggressive and well-funded de facto housing and drug treatment policy for the poor. The prison population increased by over half a million men and women during our fieldwork years and many, if not most, of these new inmates were addicted to drugs and homeless (or unstably housed) at the time of their arrest. In the wake of those decades, indigent addicts in the United States in the 2010s continue to find themselves routinely trapped in an “abusive carceral cycle.” Their criminal record, exacerbated by a low skill level imposed by years of forced idleness in a purposefully hostile prison environment devoid of rehabilitative programs (Conover 2000), condemns them to chronic unemployment upon their release. Many if not most cycle immediately back into homelessness and do not find stable shelter again until they are re-incarcerated.

The goal of the book Righteous Dopefiend that came out of this project is to render more visible to public health practitioners, social scientists, and the wider general public concerned with contemporary social problems the human physical and emotional costs of the punitive version of neoliberalism that guides U.S. public policy towards indigent drug users. Drawing on critical social science theory and some philosophy and aesthetics, we present the health crisis of the homeless as a personal narrative that documents twelve years in the lives of a cast of characters who are confined by a moral economy of sharing and mutual betrayal in the context of addiction and the criminalization of poverty (Wacquant 2009).


Team Ethnography 

Initially, we thought it would be difficult to establish a non-intrusive and ethical ethnographic relationship with the homeless who became the principle characters in our book given the fragility of their survival strategies and the everyday urgency of their drug use. They did not share our concern, however, and almost immediately integrated us non-problematically into their scene. As veteran survivor/hustlers, they recognized us as a potential resource, and most of them enjoyed being the center of our attention. They allowed us to accompany them as they scrambled for money, food, shelter, drugs and community while fleeing the police in their race to flood their bodies every day, several times a day, with heroin, alcohol and cocaine. Sometimes they coddled us as exotic, high-status outsiders. They enjoyed inviting us on visits to estranged family members, outings to the beach and visits to church. They took a certain pride in acting as expert guides when we accompanied them on scavenging expeditions and burglaries. They laid out blankets for us on the special occasions when we slept over in their encampments and on a few occasions they prayed for Jeff before going to sleep on the scavenged mattresses laid out next to him on their loading pallets in the mud. They introduced me to newcomers and transients possessively as “This is my professor I was telling you about….” Jeff was similarly introduced as, “…my photographer….”

In other words they enjoyed being taken seriously by a team of public health anthropologists and wanted to share the details of their survival strategies, dreams and multiple crises. As academics we tend to misread the real world stakes and ethical quandaries of our research. Anthropological and public health fieldwork ethics do not need to be in substantial contradiction with commonsensical, spontaneous human ethics. In the case of the homeless, for example, the best way to document the inadequacy of social services is to act as an “ethnographic accompagnateur”—akin to a social scientist version of the public health practitioner who is a community-based advocate/facilitator who promote adherence and access to medication in poor, inaccessible and underserved parts of the world (Behforouz, Farmer and Mukherjee 2004). In our case we assisted and accompanied the homeless to seek care with a secondary, complementary goal of constructively documenting the institutional mismanagement—with notable exceptions—by frontline services of poverty, ill-health and addiction. Consequently, we spent long hours attempting to facilitate (often unsuccessfully) their access to hospital emergency rooms, drug treatment centers, social service offices, community-based clinics and subsidized housing programs.

Ending an ethnographic project often feels like a betrayal of friendship, and both Jeff and I found it difficult to leave the “field.” We still feel guilty about it. This emotional quandary is inherent to anthropology's methodology and is exacerbated when one does fieldwork close-to-home across steep social power gradients. 

Jeff and I wrote the book side-by-side, but we kept interrupting our writing and analysis to run down to the corner and “check on the guys.” Inevitably, we would come back with a half dozen more pages of new fieldwork notes, a “strategically targeted” follow-up interview (or two), and a full roll (or two) of freshly shot film. We eventually had to force ourselves to disengage with the “people, places and things”—as they say in the drug treatment community—of our fieldwork scene in order to complete the book. I left San Francisco for Philadelphia in the summer of 2007 to join the faculty at the University of Pennsylvania and finally finished the final draft.

The practical, artisanal value of conducting fieldwork as a team is underappreciated in anthropology in contrast to more positivist disciplines such as public health and clinical research in which collaboration is a routine and logistical practice necessary for managing random-controlled trials or survey interview to large numbers of research subjects. Nevertheless team work can be especially productive for interpretive humanities and social sciences precisely because of their non-positivist, social constructivist commitment to critical self-reflection. Multiple ethnographers writing together can explore the social desirability effects of the positionality of the researcher, appreciate the partiality of common sensical truths, and triangulate findings (i.e., compare notes, collect alternative perspectives and strategize follow-up fieldwork).

Collaboration is also practically useful for dealing with challenging fieldwork conditions.  Daily life among homeless injectors can be emotionally draining and disorienting. They are embroiled in a politically-imposed suffering that manifests in an everyday interpersonal violence of intimate aggression and betrayal that can be destructive for them and alienating to an outsider. Conducting ethnography with a friend or colleague enables one to relax, concentrate more, and brainstorm during the very process of fieldwork itself. In the midst of the sometimes overwhelming events going on all around us, Jeff and I were able to step aside together and find a private spot to vent, strategize, joke or simply reassure one another after witnessing a particularly stormy set of arguments and hard-to-stomach events and interactions in a shooting encampment. This enabled us to stay in the field longer, feel safer, act more ethically and persevere more productively than had we been working alone. Perhaps most importantly, working as a team is also more fun.


Photo-Ethnography and the Power of Aesthetics

About nine months after the beginning of the project, I had realized that text was not going to be enough to convey the routine violence of homeless survival on the street. Nor, contradictorily, would it capture the playful—at times ecstatic—sociality of out-of-treatment addicts when self-identifying with a certain pride as outlaws. I asked Jeff to join the project as a photographer, thinking it would be a one-or-two year collaboration with a student who might benefit with a master’s thesis and an article publication. Twelve years later, the intensity of the project had bonded us as friends and as intellectual colleagues and we finally published as co-authors what we call a ‘photo-ethnography’ critiquing the mismanagement of poverty, social inequality and substance abuse in the United States (Bourgois and Schonberg 2009).

It took us two or three years of intensive fieldwork to begin to understand how to integrate photography into an ethnographic project documenting such extremely painful, politically-structured suffering in our hometown. We also had to spend precious time navigating the bureaucratic human subjects restrictions developed for clinical science that are (in my view, inappropriately) imposed on non-invasive qualitative or visual, artistic research and often stifle creativity and data collection more than they protect vulnerable research participants. The characters in our book were eager to be part of our photo-ethnographic project, and they, like us, hoped (fantasized?) we might reach a larger readership than the traditional academic and clinical/service audiences who read either social science monographs or short public health peer review journal articles.

We also wanted to try to create a historical document of the public secret of homelessness in the 2000s that most people in the United States were walking or driving-by every day without noticing. Engaging with photography made me think more systematically about the artistic dimensions of ethnographic research that I had formerly taken for granted or considered peripheral to the analytical, theoretical and practical value of anthropological and especially of public health research. My commitment to link critical social science to the practical stakes of applied public health HIV prevention work had made me overly distrust the sometimes elite preciousness of cultural studies and the aesthetically oriented focus of much humanities research. This photo-ethnographic project, however, taught me to respect both the analytical and representational potential for melding art, social science and public health.

Initially my ethnographic concern with aesthetics and artistic representation had been limited to tape-recording and editing conversations to create a cultural linguistic document and archive of the poetry, philosophy and linguistic/oppositional genius of street language and slang. In my earlier work with crack sellers in East Harlem in the 1980s and early 1990s (Bourgois 2003), I had come to realize that presenting in publications the vibrancy and playful cadence of the often charismatically distinct street voices of my research participants allowed readers to recognize the fuller creative individuality of characters. It highlighted particularly thoughtful and articulate individuals or, conversely, flagged those who might be especially vulnerable to stereotyping because of their limited access to standard grammatical English. Individual patterns of street pronunciations and orthography can also reveal patterns of dyslexia and other learning/cognition challenges that may have limited a speaker’s educational and employment opportunities.

More subtly, exposure to the often skillful oratory of long-term addicts and energetic, entry-level drug sellers helps readers appreciate the fuller humanity of a population group that tends to be dismissed as social pariah losers, criminals, sociopaths or, at best, sick, self-destructive individuals. On an immediate, practical level, extensive quotations of street-speech-in-action allows public health readers to learn the indigenous street terms useful for writing more comprehensible and relevant survey questions about risky practices. Consequently, in my fieldwork I have always conducted my interviews as free-flowing conversations in the natural environment of the respondents that I guide towards specific themes relevant to my research interests. I then complement the recordings with detailed observational fieldnotes that triangulate the self-report on the audio and enhance its meaning with descriptions of the performative body language and emotional expressions that punctuate the conversations as well as the other inaudible interactions occurring simultaneously—such as crouching or whispering to escape detection by a passing pedestrian acquaintance or police car. 

Unfortunately, I do not have the ability to think visually in the creative analytical way that Jeff does. He is able to observe, participate, audio record and photograph simultaneously without losing concentration. Within a few months of joining the project, Jeff’s fieldnotes and recordings were as good as his photographs, and soon he became as much of an ethnographer as he is a photographer. His photographic gaze gives his fieldnotes a fine-grained visual detail. Somehow he manages to take intimate pictures without interrupting social interaction. 

Initially I was crassly utilitarian in my relationship to photography and urged Jeff to be more didactically linear and illustrative of risky practices and environments with his pictures. I argued for shooting with color film. Luckily, Jeff ignored me. Color photographs might have pushed his kind of documentation of bloody injection drug use, scars, homeless filth and suffering over the top. Furthermore, black and white photography references a form of art whose long history reminds viewers of the interpretive limits of visual data. The reality they are viewing has been purposefully edited, framed and contextualized to make a point.

To avoid objectifying or trivializing the photographs, we did not accompany them with captions (except as thumbnailed appendices at the end of the book); but neither did we trust the images to stand on their own. The topics of poverty and substance abuse—not to mention HIV, crime, racialized ethnicity, childhood trauma, non-normative sexuality, and interpersonal violence—are subject to moral judgmentalism. Consequently, we embedded Jeff’s pictures strategically in the text to encourage humane as well as critical analytical readings/viewings and to diminish ethno/class-centric or righteously normative projections. I find Jeff’s photographs to be alternately beautiful, jarring, evocative and documentary. We wrapped them in text (consisting of fieldnotes, dialogues, ethnographic analysis) that is alternately theoretical, narrative, evocative, policy-oriented. Our hope is that the merger of the mediums of photography, anthropology and public health can convey more than the sum of the parts methodologically, theoretically and representationally. Once again, by imbuing social science analysis with the emotional, documentary and aesthetic power of photo-ethnography we hope to open intellectual debate to a wider audience and to promote practical engagement.

The photograph of the shooting gallery depicts the site of our social network’s primary injection locale for several months when off-the-books day labor was temporarily available selling Christmas trees on a nearby vacant lot. Jeff describes the moment he took the picture in a fieldnote that we inserted into a chapter on the legal income-generating strategies that had turned many of the homeless into inexpensive, just-in-time day laborers for fly-by-night seasonal employers.

This kind of artful, deliberately composed photograph standing alone without an accompanying text can devolve into sheer voyeurism. Jeff’s fieldnotes and the overall arguments of the book, however, prevent a pathologizing gaze by alerting readers to the logic for injecting in the midst of filth. They prevent a pathologizing gaze by showing analytically how the zero-tolerance War on Drugs has turned filthy nooks and crannies into the safest refuges for homeless injectors even though these same sites are dangerous incubators for propagating infectious diseases from the perspective of public health. On a more practical level the image conveys viscerally to public health and clinically-based readers the disjunction between hyper-sanitary HIV-prevention outreach messages and the reality of the risk environment faced by street-level addicts. 

The image also reinforces the matter-of-factness of a fieldnote that might otherwise sound like hyperbole, hallucination or propaganda. The particular chapter in which the note and photo appear traces the neighborhood’s process of deindustrialization. The details of the photo reveal the marginal “trickle-down benefits” to the indigent of the booming, high-tech digital globalized economy of the San Francisco Bay Area’s Silicon Valley, which are limited to the presence of discarded computer monitors serving as seats in this shooting gallery. This chapter has a complicated theoretical argument about the political economic historic production of marginalization. It argues for re-framing Marx’s concept of class through a redefinition of the problematic, but creative, category of ‘lumpen proletariat’ to develop a “theory of lumpen abuse under punitive neoliberalism.”

To do this, we draw from Foucault’s understanding of subjectivity and biopower, Bourdieu’s concepts of symbolic violence and habitus and Primo Levi’s insights on the invisibility of Holocaust-like gray areas in routine daily life. These concepts help us re-define the lumpen as those vulnerable populations for whom biopower (the state-mediated forces and discourses of disciplinary modernity) has become abusive rather than productive. It problematizes the blame-the-victim implications of the concept of individual agency and worthiness among members of vulnerable population groups overwhelmed by the social forces buffeting them in their moment in history. Our era’s economy, its structures of service provision, and the symbolic violence of individual achievement and free market efficiency condemn increasingly large proportions of the transgressive poor to processes of lumpenization, which decimate bodies and amplify suffering.


Public Anthropology: Homelessness, Poverty and Addiction at the Museum

The fledgling school of ‘public anthropology’ (Scheper-Hughes 2009) attempts to bring the participant-observation methodological tools and theoretical insights of our discipline to bear on the urgent social challenges of our era. Ideally, public intellectuals avoid becoming embroiled in the narrow details of partisanship or political positioning, so as to document the larger social-structural patterns that can be made visible through reflective, calm theoretical inquiry. The goal is to communicate to a wider public without dumbing-down or sanitizing an uncomfortable analysis. It requires entering policy debates and devoting energy to accessing wider media forums than those offered by our peer-review journals and university press publishers (including, with trepidation, interviews on Fox news and right-wing talk radio).

In the spirit of public anthropology we organized a photo-ethnographic exhibit at the Museum of Anthropology and Archeology at the University of Pennsylvania as well as an audio-visual installation at the Slought Foundation, an alternative art gallery, in Philadelphia. Old-fashioned, dusty-halled anthropology museums are beautiful, calm, reflective—even revered—spaces. They offer a valuable but underutilized forum for heightening the visibility of ethnographic work on public issues. The aesthetic medium of the museum display enables thoughtful audiences (who are different from those who buy and read academic books or public health peer review articles) to confront, evaluate and experience viscerally the world’s “everyday emergencies” (Taussig 1986). 

Good museum designers can translate complex historical and social ideas into a narrative with a balance of images and minimal text. The University of Pennsylvania’s museum’s exhibit designer, Kathleen Quinn, transformed the jumble of text and photographs we initially submitted to her into an elegant, succinct display that covered the six central theoretical and topical themes we had wanted to emphasize. The display was mounted on a long hallway gallery so that walking through it might approximate a quasi-ethnographic experience of homelessness, addiction, and the war on drugs with a narrative timeline that introduced several of the main characters of the book in the context of the arguments:

  1. The political economy of the lumpenization of the former industrial working class whose descendants make up the bulk of the indigent in the urban United States.
  2. The virulence of ethnic antagonism on the street, especially between whites and African-Americans, as well as its institutional reinforcement by law enforcement, social services and everyday U. S. racism.
  3. The contradiction between the War on Drugs and the delivery of public health and social services.
  4. The unintended negative consequences of social services and drug treatment that renders biopower abusive under punitive neoliberalism, exacerbating suffering.
  5. The cross-generational familial roots and ongoing interpersonal psycho-dynamics of violence, intimate betrayal and loss among friends, lovers and kin of the homeless.
  6. And finally, the moral economy of gift-giving and mutual solidarity that propagates infectious diseases but also prolongs the survival, bonding and hierarchies of street-based micro-communities of addicted bodies self-styled as righteous dopefiends.

Anthropology museums must raise millions of dollars from private donors each year to stay open. This forces them—unlike university presses or public health journals--to invest in effective public relations. The Museum’s public relations staff consequently can be another effective resource for broadcasting the message of contemporary cultural anthropology to broader audiences. For example, on billboards above two of the major freeways leading into Philadelphia, the Museum placed Jeff's “homeless Vietnam Vet photograph” of Hank waving the American flag in a ramshackle encampment, the words “Homelessness, Poverty and Addiction at the University of Pennsylvania Museum” emblazoned across his emaciated back.

The billboards pushed a ‘15-second’ critique (that could extend to 15 minutes at rush hour) of urban dualism and invisibilized inner-city poverty into an artery of suburban public space in a way we had not thought possible. The Museum ran advertisements in local weeklies including one during the Christmas holidays with Jeff’s photo of Hank hailing passersby with a misspelled panhandling sandwich sign: “Marry Christmas, need work, God Bless.”


The museum extended the exhibit for an extra year and a half (running from December 2009 to March 2012), and most interesting to us was the way community groups, homeless and addiction services organizations and educators used the space, bringing their clients/patients/inmates/students for visits and reflection sessions. A blackboard and a comment and donation box allowed visitors to leave their input. Perhaps the most moving comments we have received have been from the family members of deceased heroin injectors and crack smokers. There are few public, safe, respectful, serious and forgiving spaces that acknowledge the unresolved anger, quiet confusion and frustrated longing left among close kin by addicted loved ones who have died (Garcia 2011). Most family members are forced to mourn their lost siblings, children or parents in silence—if not shame—and they remain an invisible community. The exhibit seems to allow them to come forward and situate in history and in public policy their family’s solitary painful experience in a larger shared community. 


The more avant-garde exhibition space at the Slought Foundation of our initially simultaneous multimedia installation, “Righteous Dopefiend: Voices of the Homeless” ran for less than a month and it reached fewer viewers, primarily the web-based hipster public. More importantly, however, it introduced us to the value and untapped potential of multi-media—especially audio—installations of ethnographic material. For the exhibit, we prepared audio loops of excerpts from our hundreds of hours of recordings and combined them with photos of the daily activities of the characters speaking on the recording. This foray into audio-editing paired with photographs made us realize how much more the sound of voices communicates about racialized ethnicity, class, sex-and-gender, ethnographic rapport, suffering and human emotion than do transcriptions of these same voices frozen into print. Furthermore, the pain, anger, affectation, frustration, hopelessness or thoughtfulness of a tone of voice and turn of phrase are rendered more memorable or poignant by the photos-in-action displayed simultaneously with the audio loop. The limits of agency become evident to audiences listening to conversations-in-actions among the homeless. Stutters, pauses, self-corrections, hyperbole and emotional tones reveal personal ambivalences and bring alive the intimate structural and interpersonal quandaries and inconsistencies that condemn dreams and good intentions to failure—including, in the case of street addicts: safe injection practices, sobriety and consistent relations of social solidarity.


The Critical Potential of Anthropological Methods

Anthropology straddles the boundaries of the humanities and the social sciences, generating a scholarly space for critical epistemologies. Over the past century, anthropology differentiated itself from other social science and humanities approaches through its dedication to participant-observation ethnographic fieldwork methods that valorize participatory and subjective engagement with data collection. Fieldwork requires long-term interpersonal contact with the people and processes being researched.  Ethnographers are forced to go out into the messy, scary real world and to straddle social power divides. Ethnographers often purposefully violate de facto apartheid divisions of social class, ethnicity and normativity that structure many—if not all—social formations. 

Anthropologists cannot escape seeing, feeling and empathizing with the people they study. Our methods impel us to raise problematic questions and confront us ethically and practically with the public stakes of our writing. When our fieldwork methodology is combined with our basic good-enough heuristic principle of cultural relativism, the result can be inherently destabilizing to power, privilege and fossilized common sense. Cultural relativism has been anthropology’s foundation for combating ethnocentrism and valorizing diversity. Furthermore, it introduces an analytical space for a humble (also good-enough), critical self-reflection that is absent from public health. The hermeneutics of generosity that cultural relativism implies is an antidote to righteousness, even though it often prompts some ethnographers to sanitize their data and to bear only good news about the always-worthy people they study. Nevertheless, as anthropologists we benefit from distrusting our capacity to see, feel and report authoritatively.


Acknowledgments

Research support was provided by National Institutes of Health (NIH) grants: DA 010164. Comparative and background data was supported by NIH grants DA027204, DA027689, DA27599, AA020331 and the California HIV/AIDS Research Program ID08-SF-049. George Karandinos edited the multiple drafts and the photographs are Jeff Schonberg’s copyright. A preliminary shorter “anthropological version” of this article appeared originally in 2011 in City and Society 23:1:2-12.

Over the years, additional formal and informal collaborators on the ethnographic team included (in alphabetical order): Maxwell Burton, Dan Ciccarone, Laurie Kain Hart, Mark Lettiere, Ann Magruder, Fernando Montero, Joelle Morrow, Charles Pearson, and Jim Quesada.

Philippe Bourgois is the Richard Perry University Professor of Anthropology and Family & Community Medicine at the University of Pennsylvania. He is the author of three books and several edited volumes, including award winning In Search of Respect: Selling Crack in El Barrio (Cambridge, 1995), Righteous Dopefiend (co-authored with Jeff Schonberg, University of California, 2009), Ethnicity at Work: Divided Labor on a Central American Banana Plantation (Johns Hopkins, 1989) and Violence in War and Peace (Co-edited with Nancy Scheper-Hughes, Blackwell 2004). He has published over 150 articles on social inequality, concentrated urban poverty, violence, labor migration, ethnic conflict, homelessness, substance abuse and HIV. Since 1996 he has been the Principle Investigator on a continuously funded National Institutes of Health R01 grant examining the HIV risk environment of indigent drug users. For more information, please visit http://www.philippebourgois.net.

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