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In 1993 I was conducting fieldwork on the Fort Belknap Native American reservation when I met an oncologist from New York City during a sweatlodge ceremony. He said he was “on sabbatical” and studying with Virgil, my neighbor and an Assiniboine medicine man who was preparing to take him on a vision quest up into the Little Rocky Mountains. Marie, Virgil’s wife, told me he wasn’t the first white doctor that had come to their trailer looking for inspiration. In the coming months I learned that this doctor had experienced a professional crisis of faith. He had “fallen in a kind of plutonic love” with one of his patients who had died and found himself ill prepared to navigate the storm of feelings that the encounter had released. But what also became clear is that he had fled medicine after working over a decade in a high stress environment that discouraged any expression of emotional empathy. He hadn’t come to the mountains to escape, he said, but to find a space where he could finally acknowledge those complicated feelings.

What role does compassionate care play in the well being of medical professionals?

An expanding branch of the Well Being at Work Team research centers on the well being of healthcare workers, in particular direct care workers who work on the front lines of primary and preventive medicine. We are interested in parsing out the conditions that empower a healthcare worker to flourish, even in contexts where resources are limited. We want to know the mechanisms that create such flourishing and whether and how they can be replicated and adapted to various settings. But first we need to understand the culture of healthcare organizations; their taken for granted system of beliefs, norms, and practices; style of leadership, mission philosophy as ideal type (something to strive for) and reality (daily practice).

We need to understand various healthcare cultures that are in states of crisis, measured by poor patient satisfaction ratings and low worker engagement that result in high turnover. According to one survey of 482 U.S. healthcare H.R. employees at the managerial level or higher almost half (49%) of healthcare workers were viewed as not being fully engaged (Cornerstone 2014). Lower patient mortality and infection rates were associated with higher degrees of nurse satisfaction and engagement according to a Gallup study (Paller and Perkin 2004).

Increasingly there is mounting research to support the correlation between healthcare worker engagement and patient satisfaction pointing to the reciprocity between doctor and patient (Harmon and Behson 2007, Heskett et al. 2008). The U.S. Joint commission on the Accreditation of Healthcare organizations linked healthy workplaces to high-quality care over a decade ago: “A healthy workplace is one where workers will be able to deliver high quality care and one in which worker health and patients’ care quality are mutually supportive. That is, the physical and emotional health of workers fosters quality care, and vice versa, being able to deliver high-quality care fosters worker health” (Eisenberg et al. 2001:447).

Kleinman became the primary caregiver for his wife, his “soul mate”, after she was afflicted with a form of Alzheimer’s.

Harvard psychiatrist Arthur Kleinman has long recognized the significance of the symbiotic relationship of the healthcare encounter. In the prologue to Patients and Doctors by Jeffrey M. Borkan, Kleinman writes, “…We want to document that we are doing something whose importance lies in its intersubjective meaning, that presence of shared meaning lends a sacred quality to the medical calling…” “Presence”, he recently told a group of medical students from Rush and Western Michigan Universities, “is inherent in those who are ‘called’ into their work from a private to a public space of caretaking. Those who enact ‘presence’ are energized. It’s what makes care non-mechanical, gives care a vividness, a fullness…”

And whether intersubjective compassion and caring works through “mirror neurons” or as placebo or even through the mitigating factors of the “halo effect”, the benefits of empathy in medicine has translated into a host of measurable outcomes including higher rates of compliance, physiological evidence such as bolstered immunity and a decreased need for pain medication, and higher patient satisfaction ratings.

Scholars tend to agree that the ability to recognize and communicate an understanding of a patient’s concerns and experiences (cognitive empathy), benefits patients. But there is less consensus about whether the emotional response a physician may feel in response to encounter with a patient (affective empathy) benefits their mutual well being. Many healthcare providers feel that too much affective empathy can lead to “compassion fatigue” (a.k.a. burnout), and that a certain professional distancing is necessary in order to avoid it.

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However, a recent survey of 7500 practicing physicians showed that doctors who reported feeling concern for their patients also reported more job satisfaction (Decety and Gleichgerrcht 2013). This suggests that developing a flexible emotional intelligence that can navigate through intense encounters combined with performative acts that affirm a patient’s humanity (active listening, non clinical touch, eye contact) could improve the well being of both medical professional and patient, and that disengagement from intense emotions is not the answer.

What is often framed as care-worker “compassion fatigue” may actually be an organizational ecosystem that hinders the ability for care-workers to actually perform “intrinsically motivated” emotional care acts. What blocks an empathetic understanding of patient concerns could be a system of daily tasks and schedules, “pressures, tensions, anxiety, demoralization, dissatisfaction, frustration, feelings of guilt, reduced support and supervision (Aronson 1996), and, for those workers whose daily encounters involve witnessing grave injury and death, “complicated feelings surrounding the grief process” (Jones 2008).

Dr. Loren Hamel, the new CEO at Lakeland Regional Medical Center in St. Joseph, was born at the hospital 54 years ago. And so was his twin brother. Don Campbell / H-P staff

Dr. Loren Hamel, C.E.O. and President of Lakeland Health Care, wants to find a way to “hardwire compassion across his organization.” In 2013 hospital patient satisfaction rates hovered around the 35th percentile, so he decided to try something different and designed the “bring your heart to work” campaign.[1]

Essentially workers at all levels are encouraged to share personal anecdotes and stories with patients, to connect with them on a personal level, and actively listen to their needs and concerns. Using the framework of “Who, What, and Why” staff are asked to introduce themselves to every patient (who), communicate what they are there to do (what), and explain the reason for it (why). HR managers are paired with each patient care department to attend staff meetings and rounds throughout the week to increase employee engagement on these techniques, and thereby increase patient satisfaction.

Hearts are placed on nametags each time a patient reports that they’ve emotionally connected with a worker. At the end of each day workers share stories about how they touched their patients’ lives and in turn were “touched” themselves. Hamel recounts one story he heard on rounds of an African-American nurse who confronted a man who was out of control after learning his wife was dying. The security officers let her pass and she put her hand on his shoulder and asked if he needed a hug. He wept in her arms for twenty minutes.

Hamel explains the context that precipitated his interest in bringing “heart” back to the healthcare workplace. “I was concerned with three main challenges in our field,” Hamel says. “Healthcare is one of the most memorable dramas. Every day we deal with life and death but inevitably it becomes routine. How do we avoid this? Second, patients and their families struggle to understand what we are doing to provide care but more importantly, why we are doing it. We need to do a better job in understanding their needs and explaining why certain interventions and treatments are needed. Finally, the crisis of healthcare has beat creativity and innovation out of the industry. We have to create a space for passion in our work.”

After launching his campaign, within 90 days, patient satisfaction reached the 95th percentile across three hospitals. While Hamel expects these results to peak and valley, the implications are encouraging. Still, he wonders about their replicability. “How do you standardize a smile? How can you build a culture that supports it [empathic and passionate caregiving]? But,” he says with twinkling eyes, “if you can build a culture of compassion in medicine, well that beats strategy, rules, policy, procedure… We could measure its success through lower rates of turnover, higher rates of productivity…”

Interestingly, Hamel says that the group that struggled the most with his campaign to practice empathy was doctors. They resisted using the scripts Hamel created to guide medical professionals in their interactions with patients that used “I” statements: “I am here today because I care about your health…” Hamel says, “Some admitted, ‘I’m not up to this…letting people know how much I care.” He watched them awkwardly perform embodied acts of caring in simulation labs and realized that while transmitting empathy may be simple (involving acts such as sitting down, sustained eye contact, non clinical touch, waiting 2-3 seconds after each comment or statement, and smiling), it is not always intuitive. “We are going to keep trying,” Hamel says.

Recently a (first year) surgeon shared with me that he could not recall compassion or empathy being a meaningful part of his medical training. He wondered, given the all-consuming intensity of the technical training alone, how developing emotional intelligence could be incorporated into the curriculum. Ellen Lerner Rothman’s book White Coat: Becoming a doctor at Harvard Medical School (1999) documents the rigors and exhaustion that is part of this professional training. Rothman focuses on the doctor-patient relationship and recounts her self-doubt and unease with which she approached cadavers, conducted her first psychiatric interview and initiated her first pelvic exam. She ultimately found her calling as a pediatrician. But what of doctors who feel stuck in environments that remain high-stress and among colleagues who are chronically disengaged? I mentioned a recent news story that seemed to flag a culture in crisis: a defamation lawsuit that made headlines where a patient was awarded $500,000 after he recorded his anesthesiologist and other medical staff insulting him (she said she wanted to hit him and joked he had a STD) during his colonoscopy. The surgeon shrugged and said such scenes were commonplace.

The case for training doctors who are both technically and emotionally skilled and intelligent has produced some reforms in medical education. New scales in the MCATs, the admission test for medical school, seek to filter out those who lack the psychosocial skills essential for compassionate caregiving, and assess cultural competency and aptitude for holistic diagnosis (gauging how a patient’s background, psychology and experience impacts their health). In addition to altering the MCATs, Darrell Kirch, president and C.E.O. of the Association of American Medical Colleges (AAMC) and his team is trying to more accurately measure applicants’ reactions to patient-doctor scenarios including how practicioners interact with patients from different cultural backgrounds, as well as assess how medical professionals personally respond to stress. For according to many neuroscientists, it’s not the capacity to discern and process emotions in the workplace that is the problem, but poor stress management.

To some degree, there is a consensus among researchers that empathy can be taught so the medical training itself may be the larger issue. An often-cited study shows that empathy declines when students start seeing patients, in the third year of residency (Hojat, et al, 2009)And another has shown that doctors in practice longer are more disengaged and make less accurate diagnoses because of it. (Affective empathy has been linked to more accurate diagnoses and better patient health outcomes because patients disclose more of themselves to doctors they feel are genuinely concerned about them.) What is happening to cause this progressive disengagement?

Stressors CNAs commonly cite when they leave their positions are: unfavorable staff: patient ratio, physical exhaustion, low pay, feeling unappreciated, dissatisfied with supervisor, unable to advance, unable to provide quality of care, uninspired, and compassion fatigue (Mickus, et. al. 2004). What matters most to medical employees in a 2008 study was that management cares, listens to and appreciates them, helps with stress and “compassion fatigue”, the workplace is safe, and they have “consistent assignment” when it comes to patients. The importance of relationships as both a potential barrier and facilitator to well being is striking in this data.

Perhaps it makes good sense then to, following Hamel’s example, create an organizational culture around compassion that equips medical professionals with the tools and supports needed to offset the stressors of the workplace and a space to navigate through the emotional landscape of caring work. This may include training in reflexivity (offering classes with readings that prompt a discussion of the nature of suffering in illness and how it impacts both doctor and patient), mindfulness meditation, which helps workers to discern affective from cognitive empathy and manage their emotions and relationships effectively without disengaging, and organizing peer support groups.

According to one anonymous medical resident and writer of a popular blog, narrative medicine and the practice of therapeutic writing, even 15 minutes a day, offers another outlet, a way to embark upon the practice of medicine in a coherent, calm, and dispassionate way without slowly getting lost in cynicism or indifference. Inspired by the work of poet-physician William Carlos Williams born in 1883, the resident writes of how to live within the paradox of being a scientist-artist:

As a physician, we are constantly required to maintain our calm…We must distance ourselves enough from the human condition in order to diagnose and treat objectively, and this often requires a certain degree of reticence or repression. On the other hand, the primary goal of an artist is to express – passion, imagination, memory…The world of medicine is one of tragedy and miracles. Physicians witness death, but we also witness survival, birth, and moments of deep joy and gratitude…we return to our patients – our energy source – who inspire out poetry. This is one of the aims of the artist: to capture sparks in the ocean of humanity, to create from them a flame, and to give this flame back to the vast waters from whence they came in a new and preserved form, so that we can better understand and appreciate our collective existence.

References:

Aronson J, Neysmith SM. “You’re Not Just in There to Do the Work”: Depersonalizing Policies and the Exploitation of Home Care Workers’ Labor. Gender and Society. 1996;10(1):59–77.

Eisenberg, J.M., C.C. Bowman and N.E. Foster. 2001. “Does a Healthy Health Care Workplace Produce Higher-Quality Care?” Journal of Quality Improvement 27: 444–57.

Harmon, J. and S.J. Behson. 2007. “Links among High-Performance Work Environment, Service Quality, and Customer Satisfaction: An Extension to the Healthcare Sector.” Journal of Healthcare Management 52: 109–24.

Heskett, J.L., W.E. Sasser and J. Wheeler. 2008. The Ownership Quotient: Putting the Service Profit Chain to Work for Unbeatable Competitive Advantage. Boston, MA: Harvard Business Press.

Jones, S. H. (2008). A Delicate Balance: Self-Care for the Hospice Professional. self-care plan for hospice workers. Aging Well, 1(2), 38.

Mickus, M. C. Luz and A. Hogan. The Recruitment and Retention of Direct Care Workers in Long Term Care (2004) Michigan State University

[1]Lakeland uses the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) initiative guidelines to uniformly measure and publicly report patients’ perceptions about aspects of their inpatient care including communication with docs and nurses, responsiveness of hospital staff, pain management, hospital environment and discharge information. The survey is central to the Centers for Medicare and Medicaid’s Value-Based Purchasing Program (VBP), which encourages hospitals to provide high quality care and increased patient satisfaction through financial incentives.

compositeA recent report to CES workers on navigating the challenges of working in the field and bridging the gap between doctor and patient: http://research.nd.edu/news/64463-humanitarian-healthcare-workers-in-chiapas-mexico/

Edward F. Fischer describes the “good life” as a four-fold journey that entails “having realistic aspirations to direct that journey, sufficient opportunity to realize those aspirations, a sense of dignity and being able to pursue a life with purpose.” (Entman 2014). Of these four components of the good life: aspiration, opportunity, dignity, and purpose, I will focus on aspiration, which I conceive of as Desire, drawing from three years of fieldwork experience in the Dominican Republic.

Desire, as I’m using it here, is the ubiquitous, interpenetrative matrix of “flows” that knit life together (Deleuze and Guattari 1983) similar to Michel Foucault’s (1975) conception of power, and in contrast to Jacques Lacan’s (1977) notion of desire as Lack. This matrix maps onto our human capacity for interdependence or “friction” in a time when globalized mobility (material or immaterial) characterizes modern life. (Anna Tsing uses the term “friction” to describe what she calls “the awkward, unequal, unstable, and creative qualities of interconnection across difference” (2005:4)). As we know, what is “new” today, in terms of global mobility, is the “disjuncture between social [mobility] processes and the mass mediated discourses and practices (including those of economic liberalization, multiculturalism, human rights, and refugee claims) that now surround the nation-states” (Appadurai 1996:1999). In light of these claims, or perhaps outside of such human rights and development discourses, we must consider how people themselves define their aspirations, desires, and values amidst scarcity or loss (Jackson 2011).

figure15While interdependence, a sense of being and coming to know who we are in relation with others, is critical to well being, it is useful to consider, in our modern context of global exchange, mobility. That is, what kind of social and physical mobility do we occupy on the axis of “friction” and “flow” in our relationships? Think of the seamless travel and mobility enjoyed, for example, by the protagonist in the film Up in the Air. In that film George Clooney’s character, flown in to do the dirty business of firing employees so local managers don’t have to, relishes his frequent flyer miles and Marc Auge’s “non-place” logic (2005) of airports and generic hotel spaces where history and a sense of belonging are erased from place. Clooney’s character is so entranced in his dream of fluid mobility that he doesn’t understand that his female companion whom he meets while traveling has a “real home” (and husband and kids) outside of the mirage. On the other side of the spectrum there is “friction”, the sticky entanglements of human interaction that both anchor our sense of selves and nourish our sense of belonging and yet provide a certain amount of burden of responsibility. Going with the airport theme, think of Tom Hank’s character in Terminal, an Eastern European immigrant who loses his citizenship en route to the US and yet, stuck at JFK, creates messy and rewarding relationships with everyone of whom he comes into contact.

Hanks and Clooney’s characters illustrate a tension between extremes: “flow” as a kind of narcissistic self-enclosed freedom and “friction” as the social glue that embeds us in social relationship. Too much friction means getting stuck, and too much flow means “deterritorialization” or the lack of cultural connection to the spatial localization of place. In our globalized world, well being is situated within this axis of competing norms, values, aspirations and possibilities and thereby exists as “a field of struggle that remains elusive, transitory, and unevenly distributed” (Jackson).

Las Ballenas, a Dominican coastal village I lived in from 2009-2012,  is a borderland space dense with transnational circuits and flows where local inhabitants are experiencing the sweeping consequences of their home being mapped as a major Caribbean tourist destination. Ambiguous and contested social contracts between neighbors has followed the wake of rapid development of roads, airports, telecommunications, and cruise ship ports that connect the village center to the capital and international tourists.

Cosmopolitan guests, such as European expats who began arriving in the 1970’s seduced by the prospect of a life “off the grid” on a tropical, primitive paradise, maximize material and social privileges (pensions, passports, ethnicity) while decrying the “pirate culture” of looting, thieving, and “tiguearje” tactics (trickster like cons) that now characterize forms of exchange. While tourists, as temporary sojourners—whether lying on the beaches of all-inclusive resorts patrolled by armed guards, touring the Caribbean by cruise ship, or checking into a high- end boutique hotel—seek a more sheltered kind of leisure experience to rejuvenate their overstimulated and world weary souls.

At the same time, migration motivated by economic need rather than the desire for leisure or pleasure continues to motivate other forms of travel for Dominicans and Haitians. Young, migrant Dominican women travel from rural to urban areas, many motivated by dreams of a more affluent life married to foreigners abroad. On the other extreme, Haitians, who were denied citizenship on the grounds they were “perpetually in-transit” until recently, migrate across the island’s border or off isolated Dominican sugar plantations and are an increasingly visible and precarious presence as they physically construct tourism’s paradise as laborers in the burgeoning local construction industry. While expats seek to avoid the sticky entanglements (friction) of local politics, the state denies Haitians without mobility the kind of important social traction that accompanies citizenship rights.

Island-born transmigrants who had already experienced “afuera” (the outside) by illegal yola (canoe) to Puerto rico or by “amor para negocios” (love for business) with expats, described how “la gente ‘tan frio y no se pega” (the people are cold and lack social cohesion; literally “don’t stick”). But they also understood how increased competition following development had diminished confianza (social trust) between neighbors on the island, even among their own kin, as the traditional barter and reciprocal economy built on cooperative farming and folk catholicism (saints’ days) was replaced with a hyper competitive society based upon capitalist relations and consumer desire.

As was often the case, I, as an anomaly—an unmarried, childless foreign white woman at the time—was woven into the context of the discussion to make a point about the benefits and losses of modernity. One afternoon Marco, a security guard whose family had sold their land to foreigners and were trying to get it back, pointed out in the sea to a rock formation named after the humpback whales it resembled who came to migrate in the bay.

“Let’s say you were stuck on the whale rock with two million dollars. Now you tell me, what good is that money going to do you? Or if you are old and sick? A lot of things money can do nothing for, Delia. Look at you. You are as free as a bird, and freedom is a very important thing, but who will take care of you when you are old? [sighing] Still, ahora el dinero mueve las montanas [now the money moves the mountains].

Since tourism is an “experience economy”, where experience as the idea of social relations and cultural exchange is desired, marketed, and purchased, LB is as much about competing desires as it is a social field produced from the historical (Christian and civilizing missions) and contemporary (modernizing and neoliberal) global hegemonic conditions of political economy.

Derrida (2000) has observed that social relations, such as gift-giving or receiving someone in your home, always rest awkwardly on the border between hospitality and hostility and thus is always a fraught situation in which a hostage crisis is always imminent and mitigated by constant dialogue and negotiation. The colonial encounter is one in which the guest takes the host hostage and tourism is born of such an encounter when hosts act as servants in their own homeland, speaking the language of guests, performing various roles that meet guest expectations, but also creating “backstages” of resistance and counter-narratives where hosts challenges those representations.

Borderwork describes how boundaries around identity and roles are constructed, maintained, and transgressed between hosts and guests to reinforce notions of difference (in terms of culture, ethnicity, gender, class, or nationality) within a globalized context of tourism and migration social encounters. Tigueraje, those clever, creative strategies that allow islanders to negotiate the obstacles and uncertainties of everyday life and to contest borders (of race, sex, nation etc.) highlights those interstitial spaces where agency and structure meet within this existential field of struggle.

During my three years living in this Dominican village, I began to consider how locals use different tactics like concubine law and contesting land title to increase flow in their experience of friction in order to enlarge their social spaces and avoid getting stuck. I also investigated how expats, tourists, developers, and local elites with hyperflow (capital, passports, agency) strategize to avoid getting stuck by the friction of locals who want to secure contracts around the selling of their land and labor that maximize their cosmopolitan interests. Friction illuminates what flow effaces and allows for a processual approach to power, scale, agency, locality, and action.

Fischer refers to aspiration as “a yearning to be more than we are and have more than we presently possess” while Jackson calls it more pointedly a yearning for “a way out.” Dominicans call this proclivity toward aspiration progressando and evidence for it is everywhere from the “poco y poco” (little by little”) approach to building a concrete foundation for a home to the attention paid by young people to style and aesthetics evidenced by the intense popularity of beauty contests. Desire, rooted in the social imagination, is the engine of aspiration, an appetite that motivates our actions. We desire to be recognized by others and thereby our aspirations involve refashioning the self against certain structural borders that constrain us along lines of difference (class, nation, race, and gender/sexuality, etc.). Accordingly, desire creates social dynamics fraught with conflict and interpersonal vulnerability as well as dynamic opportunities to dream and transform our selves into something “better” or “more”.

In this stage of advanced global capitalism and information, trends in religion, consumerism, and pop culture are exported from the dominant mainstream and “indigenized” or ‘homogenized” (depending on how one measures human creativity against political economic constraints) by local populations. Populations of young people who lack access to a formal economy or education, mobility, or social capital still aspire to be modern cosmopolitans. But at all economic levels, Jackson suggests that our search for meaning and the “problem of well being and the question as to what makes life worthwhile are grounded in the mystery of existential discontent”, being haunted by loss or the thought of what may have been.

To Dominicans this aspiration is constrained by what one national report termed “forced externalization” (Ceara-Hatton 2005), the desire to emulate a lifestyle based on a dynamic, complex composite idea of Western modernity culled from the idealized other as perceived in Hollywood movies, Miami and Spanish soap operas, Columbian music videos, or even the exaggerated success narratives from returnees of life afuera (which literally means “outside” but commonly referring to New York City or Madrid). Dominican returnees, for example, rent gold chains from New York City merchandisers solely for the length of their trip back home in order to display their assumed wealth and success around their necks to family members. Local youth also demonstrate their aesthetic capital weekly in fashion and beauty contests sponsored by foreigners at discotecs (dance clubs) and beach restaurants. Retail clothing stores (often selling donated clothing from the US that Haitian vendors brought across the border) and beauty salons proliferate in town to supply this fashion market around constructing “chulo” (cool). The authors of the national report describe a Dominican “identity crisis” as national roles are subsumed under a hegemonic consumer identity. “[The] solution to the dilemmas of externality is to aspire to be “another” or at least to “seem to be another,” write the authors. Certain currents of globalization contributed to these aspirations by generalizing consumption patterns and lifestyles around the notion of “being developed.” [Ceara-Hatton 2005:6-7]

…Those who fail in their “aspiration to be another” to accumulate the other’s lifestyle and transcend class barriers may be treated as outcasts and disappear beyond the critical social gaze. Abandoned sex workers return to their mother’s houses in the countryside. Haitian laborers are deported across the border. And those suffering with SIDA (AIDS) return to the capital’s slums to die. Residents redouble their efforts in seeking protection from such a fate and pray they will not become victims to such black magic.

The pressure to succeed and emulate these idealized others contributed to aggressive borrowing/debt-incurring practices and competitive and tigueraje strategies (what happens when you cannot access the formal economy or even sell your labor). Fischer has noted that Aspiration plus Opportunity = Agency. In other words self-actualization depends upon the internal engine of desire meeting opportunity structures (material resources and social and political capital through which to exercise agency, includes social norms, ethnic and other systematic bias, principles and practice of legal rights and regulations, market entry mechanisms, self-respect that comes from mastering a practice that delimit or facilitate certain behaviors and aspirations).

When such opportunities do not exist, within relations of inequality, those operating from the margins must insert more friction into the relationship through tigueraje (cleverness); including thieving as a way to redistribute wealth and squatting to usurp land. And when those tactics fail, more direct actions of violence may occur such as the increase in armed robberies that spiked in the village in 2006. On an interpersonal level, Jackson observes that learning to negotiate the obstacles and uncertainties of everyday life may be more worthy than the search for transcendence or escape. Joking relationships, ritual ways of making light of ambiguous relationships and “laughter out of place” are also expressions of agency, of making claim to well being within a field of struggle.

 

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This is my third week with CES as our team learns more about the challenges and opportunities these pasantes face during their one year of service working in the mountain communities of Southern Mexico. Formerly considered a “punishment” for low-ranking medical students, CES seeks out high quality candidates and provides support and a “transformative” education on social justice issues to their pasantes. And something transformative is happening. A majority want to return for a second year living and serving in resource-poor communities in Chiapas.

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http://www.nytimes.com/2015/09/01/health/midwife-mexico-chiapas.html?_r=0

Pipe ceremony held before protest to gold mine. Photos by Jonathan Smart.

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A carved out mountain.

The Red Road of Resistance

By Deirdre Guthrie

In 1994, when I first arrived in Montana to work for Red Thunder Incorporated (RTI), now known as Spirit Mountain Cultural Clan, on the Fort Belknap Native American reservation, environmental racism was a fairly new term.

Organ cancer rates among Navajo teenagers living near uranium spills were reported to be 17 times higher than the national average, there were high levels of lead poisoning among African-American children in inner city housing projects, and birth defects and high cancer rates among Latino children of farm workers exposed to pesticides.

In 1992, the Southwest Network, an eight-state coalition of hundreds of multi-racial community-based organizations and individuals, formally accused the EPA, which has “trustee” responsibility for Indians through its Department of the Interior, of environmental racism by allowing harmful industrial and government facilities to be disproportionately located on reservations, as well as in communities of color and low income.

At Fort Belknap, evidence that Pegasus Gold Inc., a multinational cyanide heap-leach gold mine, threatens water quality and the health of humans and wildlife (not to mention Native cultural and sacred sites) in the Little Rocky Mountains, has finally been recognized by the Billings Federal Court. Now, the former Canadian-based multinational must pay a landmark $36.7 million dollar pollution settlement over the next five years to come into compliance with state and federal water quality laws.

According to the Billings Gazette, Pegasus violated federal and state laws by discharging acidic metal-laden wastewater from its mines in the Little Rocky Mountains into water draining into the Milk and Missouri Rivers. The maximum fine could have exceeded $100 million. Still, the settlement is the largest a mining outfit has had to pay in Montana’s history. The Gazette reports, “The mine must expand their mine waste water treatment and put up a $32 million bond to ensure that is done; pay a $2 million civil penalty that will be evenly divided between the state and federal governments; pay $1 million to the Fort Belknap tribes in partial settlement of their separate claims; and perform supplemental environmental projects estimated to cost $1.7 million.”

Back to business as usual, the state gave the go-ahead this October for extending the life of the Zortman mine five to eight more years, and its neighbor three miles away, the Landusky mine, for another year. According to Sandi Olsen of the Montana Department of Environmental Quality (DEQ), total disturbance will increase to 2,195 acres; an additional 7.6 million tons of ore and 7 million tons of waste rock will be mined from the Landusky mine; 80 million tons of ore and 60 million tons of waste rock will be mined from the Zortman mine.

That the Racicot administration has now allowed for an expansion of the mine, to more than double its size, comes as no surprise to environmental activists and the Fort Belknap community who’ve documented the mine’s unchecked, flagrant violations for years.

To tribal activists, the record of slow or non-existent regulatory action from the Department of State Lands, the Bureau of Land Management, and the Environmental Protection Agency has a long, tired history which has consistently pointed to a disturbing trend of discrimination in the region.

It has led some, like Jim Jensen, President of the Montana Environmental Information Center (MEIC), to declare “There’s such an extraordinary pattern here of failure to enforce that it seems to me that at some point down the road there should be some discussion of whether or not there has actually been a conspiracy between this company and some individuals or agencies.”

In 1991 the Billings Gazette quoted Jensen and Wil Patric, of the Mineral Policy Center, as citing 31 leaks, spills, and other environmental problems at the ZL mine over 13 years that allegedly went unpunished by department officials.

Indeed, since its opening in 1979 and its expansion through ten amendments to the original permit—none with the benefit of an Environmental Impact Statement (EIS) until now—the Zortman-Landusky mine has been plagued by an extraordinary number of serious problems and noncompliances. The litany includes cyanide leaks and spills, contaminated groundwater, a ruined aquifer, heap-leach pad mass stability failures, and bird and wildlife deaths. Prior to this year’s settlement, only one $15,000 fine by the Water Quality Bureau in 1982 was ever levied against ZL, when cyanide appeared in nearby domestic water supply taps.

Leaking containment pond and water drainage emanating from the mine. Photos by Jonathan Smart.

Leaking containment pond and water drainage emanating from the mine. Photos by Jonathan Smart.

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In late August 1993, the Department of Health and Environmental Sciences filed a lawsuit against Pegasus, alleging the mining company was violating the state water quality law. Robert J. Thompson, special assistant to the attorney general who handled the case for DHES, stated in the Phillip County News that the decision to file suit was prompted by the actions of two groups on the reservation, Red Thunder and Island Mountain Protectors (IMP).

Earlier these two tribal groups had filed citizen suits charging Pegasus with violating the Federal Clean Water Act. By DHES filing suit “on behalf of such concerned citizens,” they effectively knocked RTI and IMP out of the courtroom. RTI’s lawyer, Don Marble, believed this lightened the pressure and enforcement of Pegasus in court.

In the article, Thompson acknowledged that the violations cited in the suit had been public knowledge for some time and that Zortman Mining, Inc. had been making an effort to deal with them “but not entirely to our satisfaction.” And yet DHES still needed the actions of RTI and IMP to prompt them to file suit.

Eric Williams, public relations coordinator for Pegasus at the time, relayed the company’s intent to work with the state and added, “We weren’t surprised” by the suit. He added, “We are going to do everything we can within reason not only to continue these operations but to obtain our mine life extension permit.” Williams continued, “We see the request for those permits (discharge permits which strangely allow for the seepage of wastes) more as a policy change by the agencies. The agencies have known for some time and in some instances for several years that we have those minimal discharges up there…up until this point they haven’t said ‘you need those…discharge permits’.”

In early 1994 BLM officials admitted what Indian activist groups already suspected; that acids and metals were damaging all drainages emanating from the mine. RTI had obtained documentation showing that sulfide ores—which cause acid mine drainage—had been mined, despite the fact that the ZL’s permit was for oxide ore only. Pegasus was neither permitted nor bonded for mining sulfide ores and the operation was not designed to handle acids.

It should be noted that the ZL has the distinction of being the lowest grade gold mine in the U.S. This means that it is disturbing more ground for minute quantities of gold than any other mine (more than 60 tons of earth must be excavated for every ounce of gold that is recovered). Despite Pegasus’s record of unchecked hazards, the recent approval of its expansion allows sulfide ores to be mined—”officially.”

Olsen said, having completed the EIS for Pegasus expansion in March, the DEQ’s role is to monitor the mine to make sure it complies with state law. She said that source controls (like capping and soil barriers) and water treatment plans are in operation to prevent acid mine drainage from occurring. When asked about the risk of AMD in mining sulfides, Olsen offered, “it depends on the sulfides and their reactivity.” But what about AMD problems that went unheeded in the past? “We thought there was less of it [AMD] than there actually was,” she admitted.

For tribal activists, it seems that in spite of their efforts to diligently document violations of the mine and prepare litigation, Pegasus continues to get away with murder. Ever-present is the fear that Pegasus could pull out after gold deposits dry up, allowing the ZL mines to go bankrupt, and leave a superfund site in their wake. To add to the frustration, the Clean Water Initiative (I22) failed to win enough votes on November’s ballot (the mining industry having raised the lion’s share of 2.2 million in its campaign against the initiative).

Gary Buchanan, of Montanans for Clean Water, said I22 was launched after the 1995 legislature rewrote several laws to weaken state water-quality standards for some 100 cancer-causing materials. I22 would have required greater amounts of carcinogens, toxins, and other pollutants to be removed from mine run-off before discharging into water supplies.

Zortman

In August 1994, I accompanied a Denver Post reporter to Zortman, a small town on the south side of the reservation consisting of a bar, diner, motel, trailer park, and store.

That day we interviewed the business owners of Zortman—all of whom said they derived 99 percent of their business from the mine (1 percent from tourists, hunters, and government employees). They made it clear that without Pegasus, Zortman would be a ghost town.

As a summation of public sentiment, the storeowner pointed at a cap he sold which read: Save Montana’s Endangered Species: Ranchers, Miners, Loggers, and Sportsmen. Zortman’s inhabitants claimed that there had never been any cyanide spills at the mine, thanks to over 200 monitor wells, and that there was no problem with heavy metals. Any problems in the past with old mine tailings floating down King Creek had been graciously cleaned up, courtesy of Pegasus. They derided RTI as a radical group, or as another so eloquently put it, “assholes with moccasins.”

The store-owner stated proudly that the mine extracts 100,000 ounces of gold each year. “People need logs for their houses and gold for their rings,” he concluded. Eighty-five percent of our nation’s gold supply is used to fill this most indispensable of needs—jewelry. Walking back to the car, I read the bumper stickers plastered on the many parked pick-ups. “If it can’t be grown, mine it!” “What would the U.S. do without Zortman?”

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The Red Road

The traditionalist peoples of Fort Belknap voice that the significance of the Little Rocky Mountains rests upon the idea of the sacred. The mountains provide a physical landscape upon which the human animal can communicate with the spirit world.

Virgil McConnell, an Assiniboine elder and healer, told how sometimes someone may come and ask you to help them and you’re not sure what medicines they need. So you sweat or go to a lodge and pray. Still, nothing may come. So you have a dream and in it you may see the medicine or hear a voice.

Once Virgil heard a voice and all it said was, “Go to the mountains.” So he went. He prayed and fasted for three days. On the last day a wolf came to him with the medicine in its front paws and offered it to him. This was the cure.

Virgil wants to protect the sacred sites in the Little Rockies. The mine is steadily encroaching over the mountain range and threatening an abundance of spiritual resources. Old vision quest sites and fasting shelters are being obliterated. Animals who bring messages and guidance are being poisoned, as are the healing waters and medicinal plants.

“All the knowledge you need is up in the mountains and will never die as long as the spirits there live on,” Virgil has told me. “The only thing we pray for is to let the Great Spirit open their eyes to see the destruction, and soften their hearts so they can feel the utter pain our great mother earth has to endure because of greed and dishonesty.”

He pointed out a fork on top of the Sundance lodge, above the Thunderbird’s nest. It represents two roads; one is the shorter, easier path, the longer fork is the road of hardship but great strength. This is the Red Road, the road of resistance, whereupon the traditionalist peoples of the Fort Belknap reservation continue today to fight for their way of life.

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From: Z Net – The Spirit Of Resistance Lives
URL: http://www.zcommunications.org/environmental-racism-on-montana-reservation-by-deirdre-guthrie