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JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS FALL 2021

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Health Care and the Environment

WE ARE GRATEFUL FOR THE WOMEN AND MEN OF CATHOLIC HEALTH CARE WHO HAVE BEEN CALLED TO CARE — We stand in awe of your grace under pressure, your dedication to serve, and your commitment to the needs of others. We remain in prayerful support of the work you do for the good of all. As we continue to weather this storm together, please take the time to care for yourself as you care for others.

Our God goes before you and will be with you; God will never leave you nor forsake you. Do not be afraid; do not be discouraged. DE UTE RONOM Y 31:8

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FEATURES

HEALTH CARE AND THE ENVIRONMENT

50 MEDICAL PROFESSIONALISM AND RACIAL INEQUITY Myles N. Sheehan, SJ, MD 55 HUMAN TRAFFICKING AND THE PATH TO WHOLE HEALING Alex Garvey, PhD

DEPARTMENTS 2 EDITOR’S NOTE BETSY TAYLOR 60 FORMATION Cultivating Our Inner Environment: Three-Centered Knowing DIARMUID ROONEY, MSPsych, MTS, DSocAdmin 63 MISSION Mission Critical: Post-Pandemic Well-Being for the Vulnerable DENNIS GONZALES, PhD and KATHY ARMIJO-ETRE, PhD 66 ETHICS Vaccines: Freedom and the Common Good BRIAN M. KANE, PhD 68 HEALTH EQUITY Artificial Intelligence in Health Care Needs Scrutiny to Eliminate Bias KATHY CURRAN, JD 71 COMMUNITY BENEFIT 10 Things to Know About Community Health Workers JULIE TROCCHIO, BSN, MS

Illustrations by Larry Moore

4 HEALTH CARE SYSTEMS WORK TO REDUCE ENVIRONMENTAL FOOTPRINTS Sara Shipley Hiles 10 ADVANCING HEALTH EQUITY THROUGH CLIMATE-SMART CHANGES Lloyd H. Dean 16 UNDERSTANDING AND ADDRESSING ENVIRONMENTAL INJUSTICE AND HEALTH Laura Anderko, PhD, RN 23 ENVIRONMENTAL IMPACT AND SUSTAINABILITY: WHEN THE IMPORTANT BECOMES THE URGENT Craig Cordola, MBA, MHA, FACHE

73 THINKING GLOBALLY The Guiding Principles BRUCE COMPTON Honesty EVAN HARREL and LAURA BERLAND

15 POPE FRANCIS — FINDING GOD IN DAILY LIFE 37 LAUDATO SI’ ACTION PLATFORM 76 PRAYER SERVICE

27 SLOWLY BUT SURELY, SCHOOLS FOR HEALTH PROFESSIONS TEACH ABOUT CLIMATE CHANGE Laura Petrecca 33 PROVIDENCE’S ENVIRONMENTAL TRANSFORMATION THROUGH THE WE ACT FRAMEWORK Ali Santore 38 WATER, SANITATION AND HYGIENE: VATICAN, CATHOLIC HEALTH CARE TAKE LEADERSHIP ROLES IN ‘WASH’ WORK Susan K. Barnett 45 HOW CAN WE TURN TO THE HEALING POWER OF NATURE? Christina Leaño, MA

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EDITOR’S NOTE

aybe we should call 2021 the Year of the Multitasker? Issues that have always been important all clamor for our immediate attention in the present moment: the loss and anxiety brought about from the pandemic; the divides in our nation and culture; the real sense that long-discussed concerns about climate change have very much arrived. With spreading disease and health inequities, with wildfire, earthquake and flooding, our current moment can seem not only overwhelming, but paralyzing. What can I do when there is so much that needs to be done? That is when my time working alongside so many of you in Catholic health care helps me find an answer. To use the language of CHA’s recent meditations: Pause. Breathe. Reflect. But also then, Get Moving. We know BETSY from our traditions that those TAYLOR who shaped health care in the United States took on remarkably daunting obstacles. This Health Progress issue on “Health Care and the Environment” reflects how many health care systems continue to take on today’s environmental challenges with new goals and approaches. Not every one of us can simultaneously tackle every issue in health care today. If I were involved in the day-in, day-out frontline care of people critically ill from the pandemic, I can’t imagine I’d appreciate the suggestion that somehow I’m also supposed to tackle our environmental woes. But there is strength in our numbers, and in bringing our individual skills and talents to the specific work we can each do best for systemic improvements. Environmentalism, in a Catholic context, encompasses far more than conservation or

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recycling or renewable energy. Though those are important! It involves caring for God’s creation and, as Pope Francis has asked us, to be “generous stewards” of our resources and the earth. This issue explores the healing strength of nature; the importance of advocating for environmental justice; and a myriad of strategic and smart ways that health care systems are working to reverse actions that harm the planet to better protect patients and their environments. The work is complex and daunting in its scope. Good thing we have so many others to help us. In Philippians, Paul writes, “Have no anxiety at all, but in everything, by prayer and petition, with thanksgiving, make your requests known to God. Then the peace of God that surpasses all understanding will guard your hearts and minds in Christ Jesus.” (Philippians 4:6-7) With faith that prayer and petition can bolster us through times of challenge, we can accomplish more together than we can as individuals. And thanksgiving keeps our hearts open to remind us of all the good in our lives. What helps us in anxious times, when the work may seem overwhelming, is the remembrance that we are not alone in it.

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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON EDITOR BETSY TAYLOR btaylor@chausa.org MANAGING EDITOR CHARLOTTE KELLEY ckelley@chausa.org GRAPHIC DESIGNER LES STOCK

ADVERTISING Contact: Anna Weston, 4455 Woodson Rd., St. Louis, MO 63134-3797, 314-253-3477; fax 314-427-0029; email ads@chausa.org. SUBSCRIPTIONS/CIRCULATION Address all subscription orders, inquiries, address changes, etc., to Kim Hewitt, 4455 Woodson Rd., St. Louis, MO 63134-3797; phone 314-253-3421; email khewitt@chausa.org. Annual subscription rates are: free to CHA members; others $29; and foreign $29. ARTICLES AND BACK ISSUES Health Progress articles are available in their entirety in PDF format on the internet at www.chausa.org. Photocopies may be ordered through Copyright Clearance Center, Inc., 222 Rosewood Dr., Danvers, MA 01923. For back issues of the magazine, please contact the CHA Service Center at servicecenter@chausa.org or 800-230-7823. REPRODUCTION No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission from CHA. For information, please contact Betty Crosby, bcrosby@ chausa.org or call 314-253-3490. OPINIONS expressed by authors published in Health Progress do not necessarily reflect those of CHA. CHA assumes no responsibility for opinions or statements expressed by contributors to Health Progress. 2021 AWARDS FOR 2020 COVERAGE Catholic Press Awards: Best National Magazine, First Place; Best Special Issue, First Place; Best Layout – Scholarly Magazine, Second and Third Place; Best Color Cover, First Place; Best Column – General Commentary, Second Place; Best Pandemic Coverage, Third Place; Best Essay – Professional and Special Interest Magazine, First and Third Place, Two Honorable Mentions; Best Feature Article, First, Second and Third Place; Best Feature Article on the Election, Second Place; Best Feature Article on Racial Inequities, First and Second Place; Best Writing Analysis, Second Place and Honorable Mention; Best Reporting on Social Justice Issues on Option for the Poor and Vulnerable, First Place and Honorable Mention; Best Reporting on Rights of Workers, First Place and Honorable Mention; Best Title and Lead-In, Third Place. Association Media and Publications EXCEL: Feature Article, Gold; Feature Article Design, Silver.

EDITORIAL ADVISORY COUNCIL Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Georgia Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Holy Redeemer Health System, Meadowbrook, Pennsylvania Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pennsylvania Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Massachusetts Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis Gabriela Robles, MBA, MAHCM, vice president, community partnerships, Providence St. Joseph Health, Irvine, California Michael Romano, national director, media relations, CommonSpirit Health, Englewood, Colorado Linda Root, RN, MAHCM, chief mission integration officer, Ascension Michigan, Warren, Michigan Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minnesota

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA COMMUNITY BENEFIT: Julie Trocchio, BSN, MS CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD FINANCE: Loren Chandler, CPA, MBA, FACHE INTERNATIONAL OUTREACH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Brian P. Smith, MS, MA, MDiv LEGAL: Catherine A. Hurley, JD MINISTRY FORMATION: Diarmuid Rooney, MSPsych, MTS, DSocAdmin MISSION INTEGRATION: Dennis Gonzales, PhD THEOLOGY AND SPONSORSHIP: Fr. Charles Bouchard, OP, STD

Produced in USA. Health Progress ISSN 0882-1577. Fall 2021 (Vol. 102, No. 4). Copyright © by The Catholic Health Association of the United States. Published quarterly by The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797. Periodicals postage paid at St. Louis, MO, and additional mailing offices. Subscription prices per year: CHA members, free; nonmembers, $29; foreign, $29; single copies, $10. POSTMASTER: Send address changes to Health Progress, The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797.

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H E A LT H C A R E A N D THE ENVIRONMENT

Health Care Systems Work to Reduce Environmental Footprints SARA SHIPLEY HILES Contributor to Health Progress

he first rule of medicine is “do no harm.” Yet the health care industry itself is a major source of pollution, accounting for about 8.5% of U.S. greenhouse gas emissions in the United States and a similar share of major air pollutants.1 If the American health care industry were a country, it would rank ahead of the entire United Kingdom in emissions — and the numbers keep rising.

Dr. Jodi Sherman, an anesthesiologist at Yale University and a leader in researching the environmental footprint of the health care sector, coauthored a study in 20162 finding pollution from health care causes as much death and disability as preventable medical errors, first documented in a landmark Institute of Medicine report two decades ago.3 Just as that report sparked a revolution in patient safety practices, attention is needed now to cut health care’s pollution burden, said Sherman, who also serves as medical director of sustainability for Yale New Haven Health. “There’s very little accountability as to how we use resources as providers. We’ve known for a very long time that our expenditures are out of control, but that information is not motivating behavior change,” she said. Understanding that there is actual harm caused by the care provided, “that is new information; that is the game changer.”

LESS IS MORE

Climate change and the COVID-19 pandemic are driving awareness of the urgent need for the health care industry to behave more sustainably

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— and change is happening rapidly, if unevenly. The 2020 report of the Lancet Countdown, an international collaboration tracking health and climate change, presented its “most worrying outlook” ever, citing concerns about increased heat waves, floods, droughts, wildfires, storms, disease outbreaks, crop failures, food insecurity and rising sea levels.4 Climate change and COVID both disproportionately affect vulnerable populations, the report said, and they require global, aligned responses. Now the health care sector is starting to take action on emissions. “Just as it did with advancements in sanitation and hygiene and with tobacco control, growing and sustained engagement from the health profession during the past five years is now beginning to fill a crucial gap in the global response to climate change,” the report said. In the thick of the pandemic, England’s National Health Service last year announced its goal to become the first national health system in the world to achieve carbon net-zero, or adding no more emissions than are removed through offsets such as tree planting.5 Nick Watts, NHS’s new chief sustainability officer, said at Yale Uni-

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versity’s recent “Care Without Carbon” sympo- by 25% and reducing greenhouse gas emissions sium that the health care service can’t fulfill its by 40% by 2030. (See story on page 10.) Already mission to provide “high quality care for all, now the organization has undertaken efforts, including and for future generations” without responding upgrading lighting and HVAC equipment, plantto climate change. “We know that we can’t deliver ing trees, developing an environmentally-friendly clothing formulary and redesigning patient menus health care without that,” he said.6 The NHS committed to being carbon neu- to be plant-based.10 Sr. Mary Ellen Leciejewski, tral in its own operations by 2040 and to driving OP, system vice president of environmental susthe same reduction among its suppliers by 2045. tainability, has been leading green efforts for three “Within the decade,” Watts said at the symposium, “the In the United States, about 1,200 hospitals NHS will no longer purchase from anyone that does are members of Practice Greenhealth, not meet or exceed our coma membership organization supporting mitments on net-zero.” In the United States, sustainability solutions. Catholic hospitals about 1,200 hospitals are members of Practice Greenand health care systems are some of the health, a membership orgaleaders in this space. nization supporting sustain7 ability solutions. Catholic hospitals and health care systems are some of the decades. “Years ago, it was like pushing the rock leaders in this space, said Jessica Wolff, U.S. direc- uphill,” she said. Now, “I think the rock is rolling. tor of climate and health for Health Care With- The difference I’ve seen is, there are so many colout Harm and Practice Greenhealth. “They are so leagues who come up to me and say, ‘This is about mission-driven and values-driven, that’s why they the future of my kids and grandkids. What kind of care about this,” Wolff said. “It’s in their mission to planet will we have for them?’” (Also in this issue of Health Progress, Ascentreat the poor and the vulnerable, to care for God’s creation.” Providence, Ascension and Common- sion unveils its environmental and sustainability Spirit Health are all members of the U.S. Health objectives and goals in a three-pillar plan, detailed Care Climate Council, a leadership group advo- on page 23.) Wolff pointed to Kaiser Permanente and cating for climate action.8 Providence also announced its ambitious Cleveland Clinic as other trendsetters in polluclimate goal in the middle of the pandemic: to tion reduction. Kaiser Permanente, for example, become carbon negative by 2030 across its en– already has been certified as carbon neutral for its tire operation, including its supply chain. Beth facilities and energy sources, and the company is Schenk, executive director of environmental working on its supply chain emissions.11 stewardship, called it the boldest commitment in U.S. health care. In the past year, its hospitals have THE CHALLENGES cut waste to landfills, installed low-flow sinks and But not every hospital and health care system is on solar panels and composted food waste. “Environ- board. Only about 20% of U.S. hospitals are memmental pollution and climate pollution impact the bers of Practice Greenhealth, and a 2018 study poor and vulnerable more than those who are bet- found that only 12% of 49 large U.S. health care ter protected. It all comes back to a commitment corporations published a sustainability report, to justice,” she said. Providence’s “WE ACT” plan compared with 82% of companies on the Standard focuses on five areas responsible for the major- & Poor’s 500 index.12 ity of its carbon footprint: waste, energy/water, Being green isn’t always easy. Sherman said agriculture/food, chemicals and transportation.9 most sustainability programs start out focusing (For more details on this work, see the story on on visible waste, like recycling. “Unfortunately it is time-consuming to set up and maintain, and it page 33.) CommonSpirit Health’s sustainability plans turns out to be very low-impact” in terms of emiscall for reducing energy and water consumption sions, Sherman said. “But we didn’t know that

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H E A LT H C A R E A N D THE ENVIRONMENT

care resources go to low-value or wasteful care.14 until we started doing the research.” Disposable masks and gowns are another bug- “We spend more money than anywhere else in the aboo — but they’re only the top of the trash heap. world and our health outcomes are not at the top,” Watts of the NHS said that emissions from single- Wolff said. It turns out that climate-smart health use personal protective equipment, or PPE, were care is financially smart, too. not No. 1 or even No. 10 on his agency’s list of conSherman pointed out that sustainability isn’t cerns. “Do we need to do something with it? Yeah, just about climate change — it’s about cutting air, we absolutely do,” he said. “But it’s important to water and land pollution and responsibly using get our priorities straight as we think about what limited resources. “If we’re overconsuming matea net-zero health care system actually means and rials, we will run out,” she said. actually requires.” Where, then, does pollution hide? The main ENGAGING HOSPITALS AND PROVIDERS sources are buildings, transportation and manu- U.S. health care facilities are trying many stratefacturing of the many energy-intensive products gies to cut waste and lower emissions. used in hospitals and clinics. The supply chain — At HealthPartners, a nonprofit health care including the production, transport and disposal organization with eight hospitals in Minnesota of drugs, food, devices and equipment — makes and Wisconsin, sustainability measures have up 71% of all health care emissions globally, saved an average of $2.5 million annually since according to Health Care Without Harm. 2013, said Dana Slade, director of sustainability Big problems require big solutions, and that programs. Success stories include safer medicameans more than eliminating plastic straws in tion disposal, reducing paper use, embracing telethe cafeteria. Ultimately, health care organiza- medicine and installing solar panels.15 The biggest tions should be required to report emissions and savings have come through energy improvements draw them down in accordance with science- such as installing LED lights and adding controls based targets and timelines, Sherman said. Accountability for environWhere, then, does pollution hide? mental sustainability metrics could be enforced through the Centers for The main sources are buildings, Medicare & Medicaid Services’ pertransportation and manufacturing of formance improvement payments, she said. the many energy-intensive products

GETTING TO NET ZERO

used in hospitals and clinics.

Health Care Without Harm’s 2021 Global Road Map for Health Care Decarbonization report warns that under a “business as usual” scenario, health care’s global emissions would more than triple by 2050. To prevent that, the organization highlighted seven high-impact actions to get to zero emissions by midcentury.13 Energy consumption is the driving factor, and solving that problem means replacing fossil fuels with 100% clean, renewable electricity, according to the report. Zero-emissions buildings and transportation are next, followed by sustainably grown food and low-carbon pharmaceuticals. A “circular economy” based on clean, reusable technology is a must. Last, the report suggests establishing greater efficiency and effectiveness by eliminating unnecessary procedures and tying carbon reduction to quality of care. In the United States, about a third of health

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that can ramp heating and cooling up or down as needed. “Health care is an energy hog. We use energy 24/7/365,” he said. “That’s one of the first things to focus on.” In operating rooms — one of the most energyintensive parts of a hospital — HealthPartners has installed devices called Neptunes that suck up surgical fluids and carry them to the sanitary sewer system. Historically, that material was collected in disposable canisters and treated as medical waste, an unnecessary expense. Another innovation is sending single-use devices such as surgical scalpels and drills for reprocessing. When asked about lessons learned, Slade said that even small hospitals can be sustainable. “The other thing I’d like to emphasize is sustainability is more than just recycling or energy; it’s engaging your community and your staff about the health

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“Sustainability is more than just recycling or energy; it’s engaging your community and your staff about the health and well-being of your community.” —D ANA SLADE

and well-being of your community,” he said. At Providence Portland Medical Center in Oregon, anesthesiologist Dr. Brian Chesebro has helped to lead a national movement toward greener anesthetics. Chesebro had heard that some common anesthetics were potent greenhouse gases, and he soon learned that one was much worse than the others. Desflurane has 20 times the heat-trapping power of another gas, sevoflurane, and it stays in the atmosphere 14 times as long. Otherwise, the gases work about the same. A self-described data geek, Chesebro obtained detailed records at his hospital and showed his colleagues how they could reduce their own environmental footprints by choosing a different gas. Chesebro likes to compare using desflurane in surgery to driving a Hummer, whereas using sevoflurane is like driving a Prius. Sevoflurane is cheaper to boot. Now Chesebro speaks to audiences all over the country, and Providence’s Oregon hospitals have cut anesthesia emissions by 95%. “Physicians don’t like to be told what to do, especially ones that have long-standing clinical habits,” said Chesebro, who also serves as Providence’s medical director of environmental stewardship in its Oregon region. “The switch is pretty easy, but people need to be led through the science.” At Dignity Health California Hospital Medical Center, a 318-bed, acute-care hospital located in downtown Los Angeles that is part of CommonSpirit Health, Facilities Coordinator Kim Ray has seen a lot of changes in her 14 years on the job. When she first started, there was, to put it charitably, “a lot of opportunity” to improve sustainability. Today, the hospital has won multiple awards from Practice Greenhealth, including a “Greening the O.R.” award, thanks to its switch to bet-

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ter anesthetic gases and use of reprocessed materials.16 The hospital recycles sterile “blue wrap” and uses compostable serviceware in the cafeteria, and it was the first on the West Coast to conduct an extreme heat drill. Ray is most proud of a partnership with community group Homeboy Industries to recycle electronic waste while providing jobs for formerly incarcerated people. “We are five blocks from Skid Row, the largest homeless population in the United States. We are a true safety-net hospital,” Ray said. “I like to think if we can do it, anyone can.” SARA SHIPLEY HILES is a freelance journalist and an associate professor at the University of Missouri School of Journalism in Columbia. She is also the executive director of the Mississippi River Basin Ag & Water Desk, a collaborative reporting network.

NOTES 1. Matthew J. Eckelman et al., “Health Care Pollution And Public Health Damage In The United States: An Update,” Health Affairs 39, no. 12 (December 1, 2020): 2071-2079, https://doi.org/10.1377/hlthaff.2020.01247. 2. Matthew J. Eckelman and Jodi Sherman, “Environmental Impacts of the U.S. Health Care System and Effects on Public Health,” PLOS ONE, June 9, 2016, https://doi. org/10.1371/journal.pone.0157014. 3. Linda T. Kohn, Janet M. Corrigan and Molla S. Donaldson, editors, To Err Is Human: Building a Safer Health System, (Washington, D.C.: National Academies Press, 2000), https://doi.org/10.17226/9728. 4. Nick Watts et al., “The 2020 Report of the Lancet Countdown on Health and Climate Change: Responding to Converging Crises,” Lancet 397, no 10269 (December 2, 2020): 129-170, https://doi.org/10.1016/ S0140-6736(20)32290-X. 5. “NHS Becomes the World’s First National Health System to Commit to Become ‘Carbon Net Zero’, Backed by Clear Deliverables and Milestones,” Greener NHS, October 1, 2020, https://www.england.nhs.uk/greenernhs/2020/10/nhs-becomes-the-worlds-first-nationalhealth-system-to-commit-to-become-carbon-net-zerobacked-by-clear-deliverables-and-milestones/. 6. “Care Without Carbon: The Road to Sustainability in US Health Care,” Yale Center on Climate Change and Health, https://ysph.yale.edu/climate/phes/ sustainability-health-care-symposium/. 7. “Sustainability Solutions for Health Care,” Practice Greenhealth, https://practicegreenhealth.org.

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8. “Health Care Climate Council,” Health Care Without Harm, https://noharm-uscanada.org/ healthcareclimatecouncil. 9. “Learn How WE ACT to Become Carbon Negative by 2030,” Providence, https://www. providence.org/about/community-partnerships/ work-we-do/government-affairs-and-socialresponsibility/environmental-stewardship/ our-commitment-to-environmental-transformation. 10. “Building Healthier Communities,” CommonSpirit Health, https://commonspirit.org/a-healthier-future/ building-healthier-communities/. 11. “The First Carbon Neutral Health System in the U.S.,” Kaiser Permanente, https://about.kaiserpermanente.org/community-health/news/ first-carbon-neutral-health-system-in-us. 12. Dr. Emily Senay and Dr. Philip J. Landrigan, “Assessment of Environmental Sustainability and Corporate Social Responsibility Reporting by Large Health Care

Organizations,” JAMA Network Open 1, no. 4 (2018), https://doi.org/10.1001/jamanetworkopen.2018.0975. 13. “Global Road Map for Health Care Decarbonization: A Navigational Tool for Achieving Zero Emissions with Climate Resilience and Health Equity,” Health Care Without Harm, April 16, 2021, https://healthcareclimateaction. org/roadmap. 14. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care,” JAMA 307, no. 14 (April 11, 2012): 1513-16, https://doi.org/10.1001/ jama.2012.362. 15. “Sustainability,” HealthPartners, https://www. healthpartners.com/about/community/sustainability/. 16. “California Hospital Medical Center Honored for Environmental Sustainability by Practice Greenhealth,” Dignity Health, https://www.dignityhealth.org/socal/ locations/californiahospital/about-us/press-center/ california-hospital-medical-center-honored-for- environmental-sustainability-by-practice-greenhealth.

QUESTIONS FOR DISCUSSION Journalist Sara Shipley Hiles writes that Health Care Without Harm’s 2021 Global Road Map for Health Care Decarbonization reports that under a “business as usual” scenario, health care’s global emissions would more than triple by 2050. But the organization’s report says that the use of renewable energy; zero-emission buildings and transportation; sustainably grown food; and low-carbon pharmaceuticals will have a high impact. It also calls for reusable technology, the elimination of unnecessary procedures and tying carbon reduction to quality of care. 1. For leaders in Catholic health care: How is your health care system or facility doing with its work to reduce its environmental footprint? How does it report its efforts to employees and communities? 2. Making environmental improvements isn’t just about caring for the planet. We know the scale of health care nationally means that choices health care systems make when it comes to supply chain, energy sources, environmental waste and more ultimately impact the health of patients and their communities. At such a busy time in health care, is there a way to prioritize this work? To better support those directly engaged in it? How can you get buy-in and support from senior leadership and boards? 3. Do you think Catholic health care has been a leader in sustainability and innovative approaches to protect the environment? What more could be done? Is there a mechanism to inform leadership at your facility if someone has an idea that can lead to environmental improvement? 4. Can you articulate how this environmental stewardship work is directly related to the mission and values of Catholic health care?

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H E A LT H C A R E A N D THE ENVIRONMENT

Advancing Health Equity Through Climate-Smart Changes HEALTH CARE’S CALL TO ACTION LLOYD H. DEAN CEO of CommonSpirit Health

e are living in a pivotal moment. This new decade has been characterized by tragedy and tension, from the global pandemic to nationwide social upheaval. At the same time, our collective experience has taught us lessons sure to spark critically needed change for years to come. Among the issues justly elevated in our political and public health discourse is health equity, or the inherent right we all have to reach our full health potential, regardless of our social status or circumstances.

As we move forward, ministering to our communities effectively means being part of the effort to eliminate health disparities that persist along racial, ethnic and economic lines. This will require recognizing the inextricable link between health inequities and climate change — and examining our role as health care providers in addressing both. We are providing health care from a faithbased tradition, and, on a fundamental level, we must appreciate our planet — our home — as a gift bestowed upon us. Caring for Earth is part of caring for the people who live here. Among the measures we can take to improve health equity: we can use our resources wisely, act as stewards for environmental justice and make health care a force for healing and regeneration. By taking steps to address climate change, we can serve not only those who come to us for care, but also those in our communities and all who are

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part of the fragile ecosystem of our shared home.

THE DEBILITATING HEALTH IMPACTS OF CLIMATE CHANGE

Simply put, climate change is a public health problem. The surge in dangerous heat waves and extreme weather, worsening air and water quality, and threats to food production put human health at risk. If global temperatures continue to rise, every child born today will face more climaterelated infectious diseases, increased heart and lung damage and reduced access to food and safe drinking water. It’s important to note that these environmentally driven health impacts will continue to disproportionately affect vulnerable and underserved populations, including Black and Indigenous communities and other communities of color. For example, as of 2018, Black people in the

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United States were 40% more likely to have of the nation in meeting its climate goals under asthma than white people, according to data from the Paris Accord. I am representing Commonthe Office of Minority Health at the U.S. Depart- Spirit and the health care industry as co-chair of ment of Health and Human Services (HHS).1 A America Is All In, a coalition of representatives Princeton University study shows that Black peo- from state and city governments, tribal nations, ple also are 75% more likely than white people to businesses, and educational, cultural, faith and live near commercial facilities in the U.S. that pro- health organizations, seeking to build a more just duce noise, odor, traffic or emissions that directly and resilient economy that addresses the threat of climate change. Together, we advocate for meanaffect the population.2 Additionally, low-income Americans are much ingful policies that will put the U.S. on a path to more likely to suffer from the devastation caused cut its emissions in half by 2030 (from 2005 levels) by natural disasters due to poor infrastructure and and reach net-zero by 2050; make investments in lack of insurance coverage. Black and Hispanic communities are especially Low-income Americans are much vulnerable to extreme heat and floodmore likely to suffer from the ing because they often are clustered in neighborhoods in damage-prone devastation caused by natural areas with fewer resources to recover from disasters, according to an analydisasters due to poor infrastructure sis of data from the National Oceanic and lack of insurance coverage. and Atmospheric Administration and the Centers for Disease Control and Prevention (CDC). In fact, the CDC finds that in the clean energy sector, including creating goodthe 10 counties considered most vulnerable to paying jobs; and deliver justice to communities disasters, eight are made up of mostly Black and most harmed by climate pollution. CommonSpirit is doing its part to make tarHispanic residents.3 The numbers clearly demonstrate why, in geted, meaningful changes to address climate many ways, paving the way for health equity starts change and reduce our environmental footprint — initiatives spearheaded by Sr. Mary Ellen with environmental justice. And, though climate undeniably impacts Leciejewski, OP, our system vice president of health, we cannot ignore the health industry’s environmental sustainability. While the task impact on climate. Health care institutions are ahead can feel daunting, we are excited about the some of the largest contributors to climate change opportunities before us. In addition to our current today, as outlined in the Journal of the American goals, which will take us through this decade, we Medical Association. The U.S. health care system are beginning to develop a climate action plan that contributes 10% of the nation’s carbon emissions outlines our system goals for 2030 and beyond. Achieving these goals requires incremenand 9% of harmful non-greenhouse air pollutants. That’s more than any other industrialized health tal changes that add up, particularly as we scale across our 140 hospitals and more than 1,000 care system in the world.4 Thus, in the health care sector, we are very sites in 21 states. Step by step, we’ve made progmuch at the center of the climate crisis. We are ress toward our sustainability goals — and concharged with treating its effects on our commu- tributed to efforts across the industry — through nities, but we must also step up our leadership internal initiatives and vendor partnerships. Here through innovative climate-smart policies, prac- are some examples of our approach and what tices and public health investments. After all, an we’ve been doing to reduce waste, energy coninvestment in the health of our planet is an invest- sumption and greenhouse gas emissions: ment in the health of our patients.

AREAS OF CLIMATE ACTION AND OPPORTUNITY

CommonSpirit Health is making these investments now and seeking bolder actions in support

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Vendor Partnerships

CommonSpirit partners with vendors as they develop and launch their sustainability initiatives and services. We dove in early as a partner

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H E A LT H C A R E A N D THE ENVIRONMENT

in NewGen Surgical’s “Small Change, Big Impact” environmentally preferable purchasing program, for example. Through the program, we identified and made a single product line change — to surgical needle counters — that within two years, reduced our plastics use by more than 10 tons. The impact continues to grow. We also were one of the first health systems to work with Stryker’s Sustainability Solutions division, which provides reprocessing and remanufacturing services for single-use medical devices. Through Stryker Sustainability, devices from our facilities are collected, inspected, cleaned, tested, sterilized and packaged for repeated safe clinical use. To date, this initiative has diverted 25 million pounds of waste from CommonSpirit and other partners from landfills.

Reducing Waste

CommonSpirit prioritizes internal initiatives and vendor partnerships that align our product purchasing, recycling and waste management with our environmental goals. These include a new, sustainable approach to managing sterilization wrap. Working with Iron Mountain, we’ve created a program to recycle sterilization wrap from our facilities in a safe, cost-effective manner, while eliminating unnecessary landfill and plastic waste. As the program matures, we plan to work with a processor that will use resin from the recycled materials to create other products, such as recycle bins, bed pans and distribution totes. This will give a second life to materials that otherwise would have become waste. This summer, we began piloting a program that allows us to transform disposables into reusables. For example, we are supporting patients during transfers by introducing reusable gait belts, which use antimicrobial technology and can be washed repeatedly without losing efficacy. The initiative will roll out across the entire CommonSpirit enterprise over the next several months. Through this initiative, we will avoid sending an estimated 30 tons of waste to landfills each year. CommonSpirit also looks for business partners that work to bolster social and environmental justice in their communities. Dignity Health California Hospital Medical Center in Los Angeles, which is part of CommonSpirit Health, has a partnership with Homeboy Electronics Recycling to collect and recycle small electronics,

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such as telephones, headsets and other devices. The company provides on-the-job training and employment for people who have been incarcerated or involved with gangs. Beyond managing waste more responsibly at California Hospital, the Homeboy partnership allows us to support community members overcoming systemic barriers and transforming their lives.

Decreasing Energy Consumption and Greenhouse Gas Emissions

Understanding the state of our current facilities — and what we can do to improve them — is a key step in reducing our environmental footprint. In 2020, CommonSpirit began the process of retrocommissioning our acute care facilities, which involves evaluating, documenting and improving the operation of the building systems. The five contracted retro-commissioning vendors are working on a number of sites with the goal of implementing low- or no-cost changes that can show an immediate impact on energy reduction and lowering utility costs. This type of program has the potential to reduce utility usage and decrease utility spending by 5% to 8%. CommonSpirit also continues to explore and expand our use of sustainable energy resources, including solar energy. In 2019, we agreed to participate in a solar power initiative with Salt River Project, a community-based, nonprofit public power utility in Phoenix. Through their Sustainable Energy Offering, we acquired 4.2MW of Salt River Project’s solar farm, with our portion of the system scheduled to come online January 1, 2022. This agreement will offset more than 12,600,000 kWh of electricity that we use annually with clean, renewable energy — as well as roughly 6,000 MTCO2e (metric tons of carbon dioxide equivalent) of our greenhouse gas emissions. We also plan to use solar energy in other locations, including California and Minnesota.

THE POWER OF COLLECTIVE ACTION

Alone, none of us has the capacity to curtail the threat of climate change. It will take a whole-ofsociety approach, each one of us doing our part. Health care can make a tremendous difference — but we must act now. We need to leverage the purchasing power of our sector to invest in clean energy and sustainable products to support the transition to a healthy, equitable economy.

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I invite the leaders of all U.S. hospitals to join CommonSpirit in this work by signing up for Health Care Without Harm’s Health Care Climate Challenge and committing to action on steps to reduce your environmental footprint, build community resilience and advocate for equitable climate solutions.5 Ultimately, all sectors and all levels of government must work in collaboration to curb climate change and improve the health of all Americans. Together, we can all advance climate action for a healthier future.

PAU S E . B R E AT H E . H E A L .

LLOYD H. DEAN is CEO of Chicago-based CommonSpirit Health. Dean was previously president and CEO of Dignity Health and guided its alignment with Catholic Health Initiatives to form CommonSpirit. He is a past chair of the Catholic Health Association Board of Trustees.

NOTES 1. “Asthma and African Americans,” Office of Minority Health, U.S. Department of Health and Human Services, https://minorityhealth.hhs.gov/omh/browse. aspx?lvl=4&lvlid=15. 2. “Racial Disparities and Climate Change,” Princeton Student Climate Initiative, https://psci.princeton.edu/ tips/2020/8/15/racial-disparities-and-climate-change. 3. “Climate Impacts: Population of Top 10 Counties for Disasters: 81% Minority,” ClimateWire (June 8, 2020), https://www.eenews.net. 4. Dr. Jodi D. Sherman et al., “Reducing Pollution from the Health Care Industry,” JAMA 322, no. 11 (September 17, 2019): 1043-1044, https://doi.org/10.1001/ jama.2019.10823. 5. “Health Care Climate Challenge,” Health Care Without Harm, https://healthcareclimatechallenge.org/.

Peace in Anxiety For just this moment, bring your attention to your breath. INHALE deeply and settle yourself into your body. EXHALE the stress and tension you feel.

In these days of anxiety, a moment to pause is both a gift and a necessity. GENTLE YOUR BREATHING, your gaze and your heart as you consider:

Where have I found peace in the past days? THINK FOR A MOMENT.

In these days of anxiety where have I found peace? [Pause to consider] DWELL in the peace you have found and bring it with you into the rest of your day.

Even now, God is with you, as near to you as your breath. Continue giving yourself the gift to pause, breathe and heal, knowing you are not alone.

Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid. JOHN 14:27 © Catholic Health Association of the United States

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Photo by Giulio Origlia/Getty Images

Finding God in Daily Life “As stewards of God’s creation, we are called to make the earth a beautiful garden for the human family. When we destroy our forests, ravage our soil and pollute our seas, we betray that noble calling.” — Pope Francis from written remarks at the University of Santo Tomas,

Manila, Philippines, on Jan. 18, 2015

H E A LT H C A R E A N D THE ENVIRONMENT

Understanding and Addressing Environmental Injustice and Health LAURA ANDERKO, PhD, RN Co-director at Villanova University’s Mid-Atlantic Center for Children’s Health and the Environment

“Today, however, we have to realize that a true ecological approach always becomes a social approach; it must integrate questions of justice in debates on the environment, so as to hear both the cry of the earth and the cry of the poor.” — Pope Francis, Laudato Si’

nvironmental justice is a human rights issue and one that significantly impacts health. In his encyclical Laudato Si’, Pope Francis calls for “an integral ecology, one which clearly respects its human and social dimensions.”1 Due to wealth disparities, systemic racism, the legacy of redlining, poor land use in community planning and marginalized political influence, many communities face negative health consequences from polluting industries, natural disasters and climate change.

The people in these communities have historically faced discrimination, bearing the burden of pollution and other environmental hazards without benefitting from the protections enjoyed by communities who possess more economic, political and societal capital.2 Current policies and systems fail to meet fundamental needs that would support resiliency in overburdened communities that have traditionally been underrepresented in decision-making processes. Decades of research provides solid evidence of disproportionate environmental health risks affecting communities of color, indigenous communities and low-income people across a variety of environmental hazards: lead, air pollution, chemical facilities, mining and climate change.3-8 While health professionals have worked tire-

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lessly to address health care needs, we need a broader perspective to identify and act on the underlying causes of health disparities — especially those brought on by exposure to environmental hazards that are inherent in marginalized communities. We need to focus on justice issues, specifically environmental justice issues, to fully address the health needs of these overburdened populations. Health professionals play a critical role as they shape institutions, research, application of health practices and policies, and interactions with communities to advance environmental justice. This will require health professionals to embrace a social determinants model of health, recognizing that environmental hazards can lead to a lifetime of poor physical condition.

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ENSURING ENVIRONMENTAL JUSTICE: HISTORICAL PERSPECTIVES

accountable for detoxification and containment. It also affirms the “sacredness of Mother Earth, ecological unity and the interdependence of all species, and the right to be free from ecological destruction.”11 The principles laid the groundwork for Executive Order 12898, “Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations,” which was signed in 1994 and focuses on federal action to achieve environmental protection for all.12 However, federal action alone has not been enough to address the inequities.

The Environmental Protection Agency defines environmental justice as “the fair treatment and meaningful involvement of all people regardless of race, color, national origin or income, with respect to the development, implementation and enforcement of environmental laws, regulations and policies.” According to the EPA, environmental justice is achieved when everyone enjoys the same degree of protection from environmental and health hazards and equal access to the decision-making process that creates a healthy environment in which to live, learn and work.9 The environmental justice movement grew THE INTERSECTION OF ENVIRONMENTAL out of the civil rights movement and was INJUSTICE AND HEALTH started by people of color, who sought Understanding environmental injusto address the inequity of environtice begins with the awareness mental protection in their comthat the adverse impacts of munities. In 1982, a national, exposure to environmennonviolent sit-in protest tal hazards are not expeagainst a polychlorinated rienced equitably among biphenyl (PCB) landfill people, with race as the in Warren County, North strongest indicator of Carolina, was organized. health threats. AchievWhile unsuccessful in ing environmental jushalting construction, the tice and health equity protest is credited with requires assessment of mobilizing the environand action to address envimental justice movement. ronmental health burdens, The EPA, established in 1970, using a social determinants did not address disparities in of health framework. environmental health until Healthy, sustainable and 1990, with the creation of the equitable communities that FIGURE 1 Environmental Equity Work- SOURCE: EPA. Available at: https://www.epa.gov/ address inequities in housing, group. This group addressed environmentaljustice/resources-creating-healthytransportation, health and the sustainable-and-equitable-communities the accusation that lowenvironment through capacincome people and communities of color carried ity building, research, training and federal agency a higher environmental risk burden than the gen- contacts will result in environmental justice. This eral population.10 is accomplished by advancing meaningful comIn 1991, the First National People of Color Envi- munity partnerships that emphasize engagement ronmental Leadership Summit was held with rep- at all stages and building partnerships with area resentation from Native American, Black, Latino residents, health professionals, business leaders, and Asian Pacific populations. It created the “17 government agencies and policymakers (see FigPrinciples of Environmental Justice” to strategi- ure 1). Industrial and hazardous waste sites are more cally guide national and international efforts to achieve environmental justice. These principles prevalent in underserved communities, as are the include the right to clean air, land, water and resulting toxic emissions and contaminants that food; to participate as equal partners at every threaten health. Substandard housing conditions level of decision-making; and to demand an end found in these communities are more likely to conto the production of all toxins, hazardous wastes tain lead paint, water pollutants and mold, leading and radioactive materials with producers held residents to suffer adverse health and develop-

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mental outcomes. For example, Black children are twice as likely to be hospitalized for asthma and are four times more likely to die from asthma as white children..13 Decades of studies reveal similar health disparities in incidence and severity of cancer and developmental disabilities.14, 15 Research has shown the healing effects of nature and being outdoors on health. However, a lack of green space and parks in underserved communities reduces opportunities for experiencing the health benefits from engaging with nature.16

ADVANCING ENVIRONMENTAL JUSTICE

A number of actions can advance environmental justice and promote health equity, including expanded curricula for health professions education, systemic change and improved legislative policy.

Health Professional Education and Practice

Social determinants of health, in particular the effects the environment can have on health, have not traditionally been taught in the health professional curriculum. It is essential that these professionals become educated on the connections between the environment and health, as well as any disproportionate exposures experienced in the communities they serve. Organizations such as the Pediatric Environmental Health Specialty Units (www.pehsu.net) and the Alliance of Nurses for Healthy Environments (https://envirn. org) are dedicated to educating health professionals on a range of environmental health topics, with

larly in overburdened communities. EJSCREEN (https://www.epa.gov/ejscreen) is a mapping and screening tool that communities can use to determine health threats by accessing demographic and environmental information, such as air and water quality or lead in housing.

Institutional and Systems Change

Hospital community benefit programs, required by the Internal Revenue Service and reinforced under the Affordable Care Act, can be designed to improve community health by focusing on environment conditions, such as the quality of air, water and/or hazardous exposures. Institutions serving marginalized communities should consider identifying environmental factors in community health needs assessments and use partnerships to address social and environmental factors that negatively impact individual and community health. Community benefit programs can even address environmental issues as complex as climate change.17

Legislative Responses

While it is customary to focus interventions on individual health issues, the complex intersection of stressors and risks with the lack of social protections dictates that health professionals and society focus on the broader policy issues that increase risks for illness in overburdened, poverty-stricken individuals, families and communities. Government agencies must commit to a long-term, multisector approach that includes improvement in housing, schools, wages, transportation, environmental protecA lack of green space and parks in tions and public health measures that will underserved communities reduces protect at-risk communities and reduce poverty. The administration of President opportunities for experiencing the Joe Biden has taken important steps to health benefits from engaging with re-enact policies and legislation that will move the U.S. toward reducing greenhouse gases and improving air quality, as nature. well as addressing social determinants of a commitment to addressing environmental jus- health, such as housing.18 These measures protice issues. Educational events are offered free of vide an important launching point to build financharge and often provide continuing education cial capacity and environmental sustainability in credit to medical professionals. at-risk communities, but more must be done to In the practice setting, health professionals address the complex issues arising from the legmust promote environmental exposure assess- acy of discrimination. ment and track associated health effects to advoThe Environmental Justice for All Act, introcate for policies and programs that support the duced in Congress in March, was informed by remediation of environmental threats, particu- communities impacted by environmental racism

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Health professionals who are informed about the principles of environmental justice are better prepared to recognize environmental health risk factors in the patients, families and communities they serve. and oppression. The bill is rooted in the moral principles that all people have the right to pure air, clean water and an environment that enriches life. Building on these principles, federal policy should seek to achieve environmental justice, health equity and climate justice for all. Some of the key features of the act will address cumulative health impacts in permitting decisions under the Clean Water Act and the Clean Air Act; fund grant programs to investigate personal and childcare products containing chemicals linked to adverse health impacts; and provide more equitable access to parks and recreational opportunities for underserved communities.19 This summer, the EPA announced that it will provide $50 million for environmental justice initiatives through funds allocated under the American Rescue Plan. Congress designated this money for grants, contracts and other agency activities that identify and address disproportionate environmental or public health harms and risks in underserved communities. Examples include supporting community-based programs such as the Asthma Prevention and Control Programs, which seek to improve asthma outcomes in underserved communities, as well as outreach and education programs through the Healthy People, Homes and Neighborhood campaign.20 Advancing health equity will require health professionals to understand environmental injustices that impact the health of the communities where they practice and to advocate for a more just society. Health professionals who are informed about the principles of environmental justice are better prepared to recognize environmental health risk factors in the patients, families and communities they serve. Informed health professionals must advocate for policies that

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protect minority and low-income communities from hazardous environmental exposures and promote fair environmental policies, informed by the community. LAURA ANDERKO, PhD, RN, serves as co-director for the Mid-Atlantic Center for Children’s Health and the Environment (Federal Region 3 Pediatric Environmental Health Specialty Unit) at Villanova University, M. Louise Fitzpatrick College of Nursing, Villanova, Pennsylvania. She was recognized by the administration of President Barack Obama with the Champion of Change Award in 2013 for her work with communities to address climate change and public health.

NOTES 1. Pope Francis, Laudato Si’, (Vatican, 2015), https:// www.vatican.va/content/francesco/en/encyclicals/ documents/papa-francesco_20150524_enciclica- laudato-si.html. 2. Melanie Boeckmann and Hajo Zeeb, “Justice and Equity Implications of Climate Change Adaptation: A Theoretical Evaluation Framework,” Healthcare 4, no. 3 (2016): 65. 3. Robert J. Sampson and Alix S. Winter, “The Racial Ecology of Lead Poisoning: Toxic Inequality in Chicago Neighborhoods, 1995-2013,” Du Bois Review: Social Science Research on Race 13, no. 2 (2016): 261-283. 4. Ihab Mikati et al., “Disparities in Distribution of Particulate Matter Emission Sources by Race and Poverty Status,” American Journal of Public Health 108, no. 4 (2018): 480-485. 5. “Life at the Fenceline: Understanding Cumulative Health Hazards in Environmental Justice Communities,” Environmental Justice for All, https://ej4all.org/ life-at-the-fenceline. 6. Johnnye Lewis, Joseph Hoover and Debra MacKenzie, “Mining and Environmental Health Disparities in Native American Communities,” Current Environmental Health Reports 4, no. 2 (2017): 130-141. 7. Donald J. Wuebbles, “Impacts, Risks, and Adaptation in the United States: 4th US National Climate Assessment, Volume II,” in World Scientific Encyclopedia of Climate Change: Case Studies of Climate Risk, Action, and Opportunity, (Singapore: World Scientific, 2021), 85-98. 8. “Addressing Environmental Justice to Achieve Health Equity,” American Public Health Association, https:// www.apha.org/Policies-and-Advocacy/Public-HealthPolicy-Statements/Policy-Database/2020/01/14/.

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Addressing-Environmental-Justice-to-Achieve-HealthEquity. 9. “Environmental Justice at the EPA,” Environmental Protection Agency, https://www.epa.gov/ environmentaljustice. 10. “Environmental Justice Timeline,” Environmental Protection Agency, https://www.epa.gov/ environmentaljustice/environmental-justice-timeline. 11. “Environmental Justice Principles,” EJnet.org: Web Resources for Environmental Justice Activists, https:// www.ejnet.org/ej/principles.pdf. 12. President Bill Clinton, “Executive Order 12898: Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations. 59 FR 7629” (1994). 13. “Children’s Environmental Health Disparities: Black and African American Children and Asthma,” Environmental Protection Agency, https://19january2017snapshot.epa.gov/sites/production/files/2014-05/documents/hd_aa_asthma.pdf. 14. Gopal K. Singh and Jemal Ahmedin, “Socioeconomic and Racial/Ethnic Disparities in Cancer Mortality, Incidence, and Survival in the United States, 1950-2014: Over Six Decades of Changing Patterns and Widening Inequalities,” Journal of Environmental and Public Health

vol. 2017 (2017), https://doi.org/10.1155/2017/2819372. 15. Benjamin Zablotsky et al., “Prevalence and Trends of Developmental Disabilities among Children in the United States: 2009–2017,” Pediatrics 144, no. 4 (2019). 16. Howard Frumkin et al., “Nature Contact and Human Health: A Research Agenda,” Environmental Health Perspectives 125, no. 7 (2017). 17. Julie Trocchio, Ellen R. Tohn and Lauren Kleinman, “Community Benefit–Impact on Climate Change and the Environment,” Health Progress 97, no. 5 (2016): 69-71. 18. Juliet Eilperin, Brady Dennis and John Muyskens, “Tracking Biden’s Environmental Actions,” The Washington Post, https://www.washingtonpost.com/graphics/2021/climate-environment/ biden-climate-environment-actions/. 19. Raúl M. Grijalva and A. Donald McEachin, “Environmental Justice for All Act” (2021), https:// naturalresources.house.gov/imo/media/doc/EJ%20 Fact%20Sheet%20-%20March%202021.pdf. 20. “EPA Announces $50 Million to Fund Environmental Justice Initiatives Under the American Rescue Plan,” Environmental Protection Agency, https://www.epa. gov/newsreleases/epa-announces-50-million-fund- environmental-justice-initiatives-under-american- rescue.

QUESTIONS FOR DISCUSSION The Environmental Protection Agency says environmental justice is achieved when everyone enjoys the same degree of protection from ecological and health hazards and equal access to the decision-making process that creates a healthy environment in which to live, learn and work. 1. Did you learn about environmental justice as part of your education or after you were on the job? 2. How do environmental justice concerns affect your communication with patients? Do you make a deliberate effort to ask patients about environmental factors or social determinants of health that may be hurting or helping their overall health? Do certain factors come up over and over again? 3. Whose responsibility is it in your health care facility to consider environmental justice issues? Executive leaders, mission leaders, advocacy staff, those working in community benefit, clinicians? Is it everyone’s responsibility to be aware of environmental justice issues? Do you see this as fundamental to your role in health care, or can it just feel like one more responsibility in a time of many competing responsibilities? 4. How does understanding environmental justice tie into the health equity work your health care organization is already doing? What more can be done to make sure you’re hearing from diverse voices in the communities you serve? What advocacy efforts or collaborative partnerships can your organization pursue to address environmental justice issues at the local, state and federal levels?

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Upcoming Events from The Catholic

Health Association

Community Benefit 101: Virtual Conference

Oct. 12 – 14 | 2 – 5 p.m. ET

Global Health Networking Zoom Call Nov. 3 | Noon – 1 p.m. ET

United Against Human Trafficking Networking Zoom Call

Earn your advanced degree in

Healthcare Ethics Duquesne University offers an exciting graduate program in Healthcare Ethics to engage today’s complex issues.

Nov. 9 | Noon – 1 p.m. ET

Mission Leader Virtual Seminar

Nov. 9 – 10| Noon – 4:30 p.m. ET

Deans of Catholic Colleges of Nursing Networking Zoom Call Nov. 10 | Noon – 1 p.m. ET

Faith Community Nurse Networking Call Dec. 15 | 1 – 2 p.m. ET

2022 Long-Term Care Networking Zoom Call

Courses are taught face-to-face on campus or through online learning for busy professionals The curriculum provides expertise in clinical ethics, organizational ethics, public health ethics and research ethics, with clinical rotations in ethics consultation Doctoral students research pivotal topics in healthcare ethics and are mentored towards academic publishing and conference presentation

Jan. 11 | 3 – 4 p.m. ET

MA in Healthcare Ethics (Tuition award of 25%) This program requires 30 credits (10 courses). These credits may roll over into the Doctoral Degree that requires another 18 credits (6 courses) plus the dissertation. Doctor of Philosophy (PhD) and Doctor of Healthcare Ethics (DHCE) These research (PhD) and professional (DHCE) degrees prepare students for leadership roles in academia and clinical ethics MA Entrance – 12 courses BA Entrance – 16 courses

Questions? 412.396.4504 or chce@duq.edu

See Health Progress online at

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ENVIRONMENTAL IMPACT and SUSTAINABILITY

When the Important Becomes the Urgent CRAIG CORDOLA, MBA, MHA, FACHE Executive Vice President, Chief Operating Officer, Ascension

any of us have found ourselves at the intersection of health care and the environment. For me, one of the most impactful moments took place earlier in my career, serving in the aftermath of Hurricanes Katrina and Rita. I will forever remember sitting at our transfer center in Houston around midnight, watching our helicopters, fixed-wing aircraft and ambulances set out for New Orleans to help evacuate people to our city. In the days to come, busloads of people arrived at the Astrodome and the convention center, where we were providing care. They came with nothing other than what they could carry — totally displaced from family members, dropped off in an unfamiliar city. It impressed on me that when the fabric of a community breaks down following a natural disaster, you really don’t have normal infrastructure and processes. Things like security, safety, food, access and relationships get stripped away. Katrina left both cities forever changed. All because of a natural disaster, exacerbated by climate change.

As I reflect on Katrina and Rita, and the countless wildfires, floods and extreme heat events that have happened since, I am struck by the immediate and lasting impact these events have on individuals and communities, especially for those people who are poor and vulnerable. Health care’s impact on the environment is significant and inextricably linked to the health of the communities and patients we serve. Compelled by our mission to sustain and improve the health of individuals and communities, it is our time to respond in a new way. We have recently challenged our health ministry to take a greater role in leading transformation around environmental impact and sustainability. We have asked ourselves: What if there was a way to change health care as it relates to environ-

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mental impact and sustainability so that it has a profound effect on our coworkers, our patients and the communities that we serve? How does this work integrate into our ministry to bring about meaningful, sustainable change over time? How can we harness the power of 160,000 employees and their families and all the people they impact to make a tangible difference to our patients and communities — and likely change health care as a whole? As a health care ministry, rooted in our Catholic faith and social teaching, we believe it’s an expectation and enormous opportunity for us to approach our work in a different way. Care for God’s creation is one of the principles of Catholic social teaching and serves as a beacon for all of Catholic ministry to lead the way on environmental sustainability.

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THREE PILLARS

To find answers to these complex challenges, Ascension recently developed a long-term environmental impact and sustainability program to augment our continued efforts around energy conservation, waste management, recycling, environmentally preferred purchasing and the use of renewable fuels. With guidance from executive and senior leaders, as well as internal and external subject matter experts, we developed the following purpose statement to guide our work: “Ascension’s commitment to reducing our environmental impact and achieving sustainability is rooted in our Mission, which calls us to be advocates for a compassionate and just society in our actions and our words. Through Catholic social teaching, we recognize the human dignity of all people and the common good as we work toward equitable access to resources to improve the community health and the lives of individuals we serve.” We will work across our ministry to set goals to improve our efficiency, resiliency and sustainability as we continue to provide the health care our communities need and future generations deserve. The renewed focus is the result of a yearlong effort to develop a sustainability strategy that will maximize environmental impact for decades. This program will focus activities in the following three pillars:

NET ZERO PLACES

This work is focused on carbon sources associated with our physical environments — energy management, water management and mobility, both moving within those environments and getting to and from them. This pillar considers the carbon footprint and operational efficiency of our facilities as well as sustainable transportation. Objectives: Ascension seeks to create and support a resource-efficient, cost-effective and resilient ecosystem of our facilities and real estate with minimized impact to the environment and maximized care to patients and associates. The goal: Net zero carbon with absolute emissions reduction by 2040.

RESPONSIBLE SUPPLY CHAIN

This work is focused on the flow of goods, from procurement through their disposition after use. These responsible supply chain efforts address responsible purchasing — to ensure we buy only what we need — as well as sourcing and waste management. Together, these efforts will lower environmental impact and provide social good. Objectives: Ascension seeks to create and support a cost-effective, healthy, circular and resilient value chain that accelerates change toward a value-based care model, in alignment with our commitment to holistic care for the person and the common good as well as to Catholic social teaching. We have a tremendous opportunity to change our work in supply chain management on what comes in and out of our facilities as well as the impact on the footprint that we leave behind. The goal: Recycle 50% of nonhazardous waste from all managed facilities by 2030; zero waste by 2040.

HEALTHY COMMUNITIES

Most of our work to this point has focused on realizing energy savings and thinking differently about how we

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H E A LT H C A R E A N D THE ENVIRONMENT

The impacts of climate change are worsening and will profoundly affect the Social Determinants of Health1

acquire and run our facilities. But the heart of our environmental impact and sustainability program is our efforts toward healthy communities. Objectives: We are examining our communities and social determinants of health as well as designing programs and processes that support clinical interventions to address environmental effects on patients and create healthier environments in communities we serve. The goal: We will work closely with the individuals and communities most impacted by climate change to improve their lives and livelihood. Other intended outcomes include safer, healthier communities, improved patient comfort and improved patient safety (see graphic above).

EARLY SUCCESS STORIES

We are taking a fresh look at Ascension’s sustainability initiatives to expand and enhance our ability to infuse greener thinking across the organization, including acute care and ambulatory facilities as well as administrative and office settings. These initiatives continue work that has been underway for more than 15 years. The early successes described below highlight ongoing com-

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mitment and pave the way for the goals we have set for the future.

Green Teams

Ascension’s environmental sustainability efforts have largely rested on the contributions of our Green Teams, employees at each facility who are interested in mitigating the local impact of their facility on the environment. Green Teams also report on energy, water and waste management for their facility or market. We’ll continue to weave environmental principles into everything we do through these interdisciplinary teams. There is also an inherent link between these Green Teams and our Catholic identity. Ascension uses a Catholic Identity Matrix (CIM) to assess and enhance the degree to which our markets integrate Catholic moral principles within our operating policies, processes and practices. One of the six principles included in the CIM involves environmental sustainability. Green Teams extend this mission-oriented principle more fully. Through these teams, associates are encouraged to participate in Earth Day and Feast of Saint Francis events as well as volunteer at community

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n his encyclical Laudato Si’, Pope Francis made a plea for leaders who would create the culture needed to confront this important work: “Never have we so hurt and mistreated our common home as we have in the last 200 years. Yet we are called to be instruments of God our Father, so that our planet might be what he desired when he created it and correspond with his plan for peace, beauty and fullness. The problem is that we still lack the culture to confront this crisis. We lack leadership capable of striking out on new paths and meeting the needs of the present with concern for all and without prejudice toward coming generations.” (Paragraph 53)

gardens, help with recycling events, plant trees and more.

Better Buildings Challenge

During the recession of 2008, the need to reduce costs motivated Ascension to track energy use as the first environmental sustainability metric to be monitored at the system level. After meeting an initial goal of reducing energy use by 5% in 2011, Ascension committed to a 20% reduction in energy use by 2020 as part of the U.S. Department of Energy’s Better Buildings Challenge. From mid-2008 through 2016, Ascension reduced energy usage by 21.4%, achieved $53.3 million in cost avoidance and avoided over 1,114,600 tons of carbon dioxide emissions across 141 health care facilities. As hospitals realized the value of improved energy efficiency, they asked about additional related strategies, such as recycling programs, safer chemicals and environmentally preferred purchasing.

Waste Diversion

The Resource Group, Ascension’s group purchasing organization, has led the way to reprocess and recycle single-use devices (SUDs). This initiative cuts down on waste sent to landfills and reduces expenses. SUDs are now collected and sent to reprocessing centers to be cleaned, recalibrated, repackaged and resterilized for multiple uses. Along with the benefits of reprocessing, Ascension also recycles SUDs that have been used

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by providers the maximum number of times allowed by the U.S. Food and Drug Administration. These devices can be reprocessed anywhere from one to 10 times. Once a device has run its course, rather than throwing it away, our ministries now focus on recycling these items. In the 2020 fiscal year, Ascension hospitals collected 1.4 million devices, resulting in $19 million in savings and 700,000 pounds of waste diverted from landfills. Since the program’s inception in FY13, 4.5 million pounds of waste has been diverted.

Antibiotic-free Food

Through a collaboration with the Health Care Climate Council, the Healthcare Anchor Network and Practice Greenhealth, Ascension has participated in market transformation groups. The first group initiative was called “Less Meat, Better Meat.” We worked closely with our food and nutrition services partner as well as our infection control team to advocate buying poultry raised without the use of antibiotics. Through collaboration and work to change the markets, we helped ensure that such food became available.

THE IMPORTANT HAS BECOME THE URGENT

As we look at what lies ahead, we are convinced that care of God’s creation is not only important; it is an urgent matter that demands immediate attention. When I think about my children and future generations, our employees and the patients and communities we serve, I realize how the work of environmental sustainability cannot wait. Wildfires and floods, hurricanes and extreme heat will increasingly affect our health — further compounded by social determinants impacting those who are poor and vulnerable. Now is the time to reimagine what environmental impact and sustainability could look like for the next decade and beyond. We encourage other Catholic health care leaders to join us as, to paraphrase Pope Francis in Laudato Si’, we strike out on new paths and meet the needs of the present with concern for all and without prejudice toward coming generations. Together, we will make a difference. CRAIG CORDOLA serves as executive vice president and chief operating officer for Ascension, St. Louis.

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H E A LT H C A R E A N D THE ENVIRONMENT

Slowly but Surely, Schools For Health Professions Teach About Climate Change LAURA PETRECCA Contributor to Health Progress

n their first year as students at the Emory University School of Medicine, Ben Rabin and Emaline Laney noticed something blatantly missing from their curricula: any information on the consequences of climate change.

They knew environmental elements could affect patients’ mental and physical health, yet they weren’t getting any training in that area. “The impacts of climate change permeate every organ system,” says Laney. “Despite this, there was no mention of climate change in our medical education.” Yet, instead of just continuing with the status quo, “we decided to change that,” she says. The duo connected with Dr. Rebecca Philipsborn, an assistant professor of pediatrics and pediatrician who had published literature about the health effects of climate change, to launch a lunchtime panel discussion about climate and health. Buoyed by the success of that event, they tackled a more ambitious idea: develop a climaterelated curriculum that would be taught to every Emory medical student. Under the mentorship of Philipsborn, Rabin and Laney outlined topics and learning points on climate change and health that intersected with existing content. “It took a tremendous amount of work,” says Philipsborn. They submitted and presented their proposal to several committees, and in October 2019 — just over one year from when they began medi-

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cal school — got the green light from the medical school’s executive curriculum committee. Beginning in 2020, every incoming medical student started learning the new material.

THE CALL FOR CLIMATE EDUCATION

Emory is one of many schools responding to the call to teach future health care professionals about the consequences of climate change. Some offer courses and certificates, others are weaving relevant case studies into existing material, and still others are welcoming environmental experts as guest lecturers. Educational institutions are being encouraged — and prodded — to make these changes by a wide range of influential sources, from students to environmentalists to Pope Francis. The updates come as areas across the globe experience devastating heat waves, droughts, storms and floods. While doubters remain, the evidence mounts that people worldwide are negatively affected by climate change. Early in the summer of 2021, a record-breaking heat wave across the U.S. Pacific Northwest and western Canada caused hundreds of deaths. The temperatures spiked so high that medical professionals

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H E A LT H C A R E A N D THE ENVIRONMENT

said severe burns could occur by just stepping barefoot on asphalt. The World Health Organization has warned that a changing climate could account for an additional 250,000 deaths each year between 2030 and 2050 due to malnutrition, malaria, diarrhea and heat stress alone. And the U.S. Environmental Protection Agency says climate changes can lead to a host of ailments, from increased allergies due to a prolonged pollen season to a greater potential for Lyme disease from the expansion of hospitable tick habitats. Today’s medical students “will be caring for individuals whose health will be impacted — directly or indirectly — by climate change,” says Ann Marie Sailsman, a doctor of nursing practice and clinical assistant professor at Seton Hall University’s College of Nursing. “As health educators, we must prepare them to handle these challenges.”

“Most of the people who teach in professional schools aren’t well versed in environmental science and climate change,” he says. “They’re not experts in that area, and there’s not an easily identifiable way to deliver that content.” Another issue, say faculty members, is that educational institutions are extremely focused on preparing students to pass their licensing exams. If the material isn’t on an exam, they say, there isn’t a strong incentive for the school to focus on that subject matter. “Until we get climate change questions in the licensure exam, that is going to be a barrier to implementation,” says Ruth McDermott-Levy, PhD, who is a professor, nurse and co-director of the Mid-Atlantic Center for Children’s Health and the Environment at Villanova University’s M. Louise Fitzpatrick College of Nursing.

Today’s medical students “will be caring for individuals whose health will be impacted — directly or indirectly — by climate change.”

CHALLENGES TO CHANGE

While schools increasingly embrace climate-change curricula, the overall adoption remains low. For the 2015-2016 academic year, just 4% of medical schools said they had climate change or global — ANN MARIE SAILSMAN warming-related content, according to the Association of American Medical Colleges’ For instance, she says, “if there were test analysis of curriculum submitted by participating questions on the NCLEX [nursing] examination schools. For the 2017-2018 year, that grew to 9%, related to climate change, schools of nursing and for the 2019-2020 year, it hit 17%. would be highly motivated to include that content School representatives cite a range of reasons in their curricula.” for delaying and disregarding implementation of this material. Among the reasons reported in a RESOURCES ABOUND survey by the Global Consortium on Climate and McDermott-Levy says that adding climate change Health Education at Columbia University’s Mail- material doesn’t have to be a heavy lift. A plethora man School of Public Health: lack of available staff of public material is available, such as the Global time, lack of funding, competing institutional pri- Consortium on Climate and Health Education’s orities and/or politics, lack of space in the core site, which has syllabi and program plans, slides curriculum and a lack of teaching materials and and videos and government sources such as Glostaff expertise. balChange.gov. “A challenge we find is where to put it in the The Alliance of Nurses for Healthy Environcurriculum because (medical students) are ments (ANHE), of which McDermott-Levy is a already so busy trying to learn the basics,” says member, has a 12-page outline titled “Strategies Patrick Swanson, PhD, professor in the Depart- for Incorporating Climate Change into Nursing ment of Medical Microbiology and Immunology Curricula.” ANHE is “trying to work with faculty at Creighton University School of Medicine. As across the United States to show them how easy it chair of the medical school’s Planetary Health and is to put this into courses,” she says. For example, Sustainability Committee, he works with fellow a pediatrics lecture could include information on faculty to add more materials related to climate potential heat issues from playing outside or the change to the school’s teachings. risk of disease from tick bites.

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CASE STUDY

o teach students about the ways that the environment can affect patients’ health, schools give them case studies to outline the complexity of cases they may see, the ways health issues may intersect and encourage discussion on how to best treat the patients. This condensed case study is courtesy of Better Together — Health Sciences of the University of Minnesota. The instructor provides an overview of planetary health issues, then asks students to individually read through this case scenario, before they move into small group breakout rooms to discuss the questions in a workbook with student peers. Ana is a 53-year-old woman who fled her native country of El Salvador in 2000 after a devastating hurricane shut down the coffee plantation where she worked. She first went to Mexico with several extended family members, and then they moved to the U.S. in 2015. She misses her community in El Salvador, but she has worked hard to build a new home in America. Ana lives with five other members of her extended family in a small, un-air-conditioned manufactured home in the rural town of Cold Spring, Minnesota. The adults in her home are employed in low-wage jobs, such as cleaning, farm labor and nursing aides in long-term care facilities. Ana is an undocumented worker on an assembly line in a poultry processing plant. She works 10-hour shifts, and the work is very physically demanding. She stopped going to school at age 12 and has limited English-language proficiency. She needs to keep her job in order to meet her expenses and to send money to family members in El Salvador. She fears being detained or arrested, so she has not applied for economic or medical assistance, but she occasionally utilizes a local free migrant health clinic. There never seems to be enough food in her home, and fresh produce

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is too expensive. Ana is eating a lot of processed foods and is now overweight. She has noticed her chronic asthma has gotten worse over the past three years. Over the same time, there have been record rainfalls and prolonged soil moisture near her home and high particulates in the air from Western forest fires. When COVID-19 began to impact her town in March 2020, Ana worried about her health and the health of her family members and co-workers. She and her extended family members also feared losing their jobs if they stayed home from work. Ana and most of her family members were classified as “essential workers” as the pandemic took hold in their area, and they risked getting sick while at work. Their employers were slow to provide them with proper protective gear and Ana, along with nearly 200 of her co-workers, tested positive for the coronavirus in April 2020. She suffered relatively mild symptoms from the virus, and except for some persistent fatigue, she has recovered. Ana’s physical and mental health are being impacted greatly, and she is also enduring intense personal and economic pressures. She is struggling to manage her health issues, and she feels a great deal of uncertainty and fear relating to the global pandemic. She no longer sleeps well, either. Her insomnia is especially troublesome when there is heavy rainfall, probably because it reminds her of the traumatic hurricane she experienced back in El Salvador. The doctor at the migrant health clinic has said that her asthma, anxiety, stress, low nutritional, high-caloric food intake and intermittent insomnia are all contributing factors to her new diagnosis of high blood pressure. Ana is overwhelmed when she tries to think about how she can possibly manage this along with everything else, and she knows she cannot afford the medication that her doctor has suggested.

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SMALL GROUP DISCUSSION 1. Individually, list changes in the environment and health of the planet that have contributed to Ana’s health issues. Then, take turns sharing your lists. 2. Discuss these questions as a group: Should planetary health be a responsibility of health professional students, practicing health professionals and the organizations they work for? If yes, why? If no, why not? What specific measures can be taken by health professionals and health care organizations in our daily work to improve planetary health? Consider the uni-professional vs. interprofessional collaborative responses to this case study, including what responses would be appropriate for Ana’s situation. How is collaboration going to be important in addressing the needs of individual patients? For addressing the larger issues of planetary health and global pandemics? Worsening planetary health adversely affects the health of some populations and groups more than others. Some people believe the declining health of our planet is a justice and equity issue. Which populations and/or groups suffer the most as planetary health declines? How can cultivating a shared understanding and shared sense of responsibility about these larger issues of planetary health and global pandemics contribute to improved population health and improved patient experiences, while also reducing the cost of health care?

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H E A LT H C A R E A N D THE ENVIRONMENT

Swanson says Creighton uses information from the readily accessible Academic Medicine article “Climate Change and the Practice of Medicine: Essentials for Resident Education” as a guide for integrating relevant material. The school is working to integrate the material “horizontally” across existing classes. For instance, he says, a lecture on the respiratory system can touch upon how air pollution can affect humans. “It’s not too much of a stretch to bring in this connectivity,” he says. Seton Hall’s Sailsman uses publicly available resources as well. For the last three years, she has woven climate change-related topics into her community health and population health lectures. She also incorporated similar material into a Climate Change and Health module that will be part of a new online course, Determinants of Population Health Nursing Perspectives, slated to be offered this spring. In the new course, students will be asked to take an online quiz to test their global warming knowledge, read climate change-related textbook chapters and articles and watch TED talks, such as teenage climate activist Greta Thunberg’s “The disarming case to act right now on climate change.” Sailsman says she encourages candid climaterelated conversations among students. “We always have a spirited discussion, and so much learning comes out of that,” she says.

MANY SOURCES OF MOTIVATION

Medical schools have plenty of motivation to embrace climate change curricula. In recent years, medical associations have become bigger proponents of incorporating this material. In 2019, the American Medical Association adopted a resolution that supported “educating the medical community on the potential adverse public health effects of global climate change and incorporating the health implications of climate change into the spectrum of medical education.” And in spring 2021, the American Association of Colleges of Nursing updated its core competencies for professional nursing education, known as “The Essentials,” to include a new expectation that nursing program graduates will understand “the impact of climate change on environmental and population health.” Some schools, such as Penn State, look to the United Nation’s Sustainable Development Goals

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for guidance, while other schools go to an even higher power. Swanson says the inspiration for Creighton’s increased focus on climate change was Pope Francis’ 2015 encyclical Laudato Si’, in which the pope appealed for better safekeeping of the planet and emphasized the need to care for “our common home.”

STUDENTS FOSTERING CHANGE

Another reason why schools are making change: vocal and proactive students, such as Emory’s Rabin and Laney, are demanding this content. Students are a “driving force for incorporating climate change into our curricula,” says Swanson. Organizations like Medical Students for a Sustainable Future (MS4SF) are gaining members and momentum. This network of more than 400 medical students from 105 medical schools, aims

Students are a “driving force for incorporating climate change into our curricula.” —PATRICK SWANSON

to address the climate crisis through advocacy, curriculum reform, sustainable health care and other initiatives. Swanson says he uses the organization’s Climate and Health Curriculum Reform Guide as a reference. At Loyola University Chicago Stritch School of Medicine, members of the Group for Environmental Medicine and Sustainability (GEMS) are working to update their curriculum. Students created a plan for an elective that would address “the many possible intersections of the medical field and climate change,” says medical student and GEMS board member Emma Stewart. The proposal was submitted to the assistant dean of educational affairs with hopes that the course will be in effect by spring 2022, says Stewart. At the same time, students are increasing their scrutiny of schools. The Planetary Health Report Card, founded in 2019 by medical students at the University of California San Francisco, invites medical students to grade their schools in five main areas: planetary health curriculum, interdisciplinary research in health and the environment, university support for student planetary health initiatives, community outreach centered on environmental health impacts and sustainability. The

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results are then published in an extensive report.

FOCUS ON PLANETARY HEALTH

Despite support from major medical associations and increased pressure from students, individual educators remain ultimately responsible to take action, says Teddie M. Potter, PhD, a nurse and clinical professor who serves as director of planetary health at the University of Minnesota School of Nursing. She also is the faculty lead in incorporating climate change into the school’s curricula. “It’s going to fall on faculty to say, ‘Wait a second. Our deepest commitment is to prepare effective health professionals for the future to protect the public,’” she says. She and other faculty at schools for health professions stress that education needs to go beyond just teaching students how climate change can affect a patient’s health and encompass the broader topic of planetary health. Students need to learn about the carbon footprints of hospitals, how medical supply delivery can be disrupted by extreme weather, how the disposal of medications affects our environment and much more. “If we are not dealing with this huge cause of human disease burden — disruption of the planet — we’re not adequately preparing our students for the future,” says Potter. “This is a critical issue. ... If the earth were a patient, (it) would be in the intensive care unit in multi-system failure.” LAURA PETRECCA is a writer and editor who has covered a wide range of health, business and breaking news topics — from climate change to corporate mergers. She is the former business section editor and New York City bureau chief for USA Today. Her writing has appeared in Real Simple, Men’s Health and AARP, among other publications.

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EDUCATIONAL RESOURCES

here’s a wide range of helpful resources for schools exploring the notion of incorporating climate change into their curricula — as well as those who want to expand upon existing programs. They include: Global Consortium on Climate and Health Education: Launched in 2017 by faculty at Columbia University Mailman School of Public Health, this international forum is dedicated to helping health professionals prevent, mitigate and respond to the effects of climate change. Medical Students for a Sustainable Future: This network of more than 400 medical students aims to tackle climate change-related health and social justice issues through advocacy, curriculum reform, sustainable healthcare and other initiatives. Alliance of Nurses for Healthy Environments: The mission of this group of nurses and nursing organizations is to promote “healthy people and healthy environments by educating and leading the nursing profession, advancing research, incorporating evidence-based practice and influencing policy.” Health Care Without Harm: This nonprofit wants to transform the health care industry worldwide by improving sustainability efforts and reducing environmental harm. Health Care Without Harm also advocates for environmental health and justice. Planetary Health Alliance: This global coalition of more than 200 members — including universities, research institutes, non-governmental organizations and government groups — aims to better understand and address the effects of environmental change on the population while also supporting Earth’s overall health.

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H E A LT H C A R E A N D THE ENVIRONMENT

Providence’s Environmental Transformation Through The WE ACT Framework ALI SANTORE Chief advocacy officer, Providence

very community around the world faces the existential crisis of climate change. As a direct result of this crisis, the negative impact to human health will affect current and future generations.

Air pollution, heat waves and extreme weather increasingly negatively influence human health, according to a December 2020 analysis by The Lancet.1 At the same time, the U.S. health care sector contributes 8.5% of all greenhouse gases produced in the nation.2 The health care sector’s impact results from fossil fuel consumption, byproducts of chemical use and production of excessive waste. Scientists have indicated that climate change is the crisis of our time and swift change is of the essence. Prompt and prudent change made during the current decade will determine whether humans can limit global temperature rise to a manageable amount for generations to come.3 At Providence, we recognize our responsibility to act now and challenge others in our industry and beyond to do the same. We can only change the course of this crisis through collective action. Our vision of health for a better world calls us to care for the most vulnerable and our precious resources through environmental justice and stewardship. Core to Providence’s plan is the dramatic reduction of our carbon footprint. Our goal: Providence will be carbon negative by 2030.

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Providence is composed of 52 hospitals, more than 1,000 medical clinics, senior services, supportive housing and other health and educational services. Together with our partners we employ more than 120,000 caregivers serving communities across seven states — Alaska, California, Montana, New Mexico, Oregon, Texas and Washington with system offices in Renton, Washington, and Irvine, California. We have scoured operations and procedures to find opportunities to serve patients, employees and our communities for ways to reduce our footprint. We acknowledge that this effort must be a perpetual commitment to improvement. We invite others to join us as we seek to improve the health of our planet and our communities.

THE VISION AND THE PLAN

In 2020, on the 50th anniversary of Earth Day, Providence announced the goal to become carbon negative by 2030. This announcement was particularly meaningful, as we are still on the front lines of fighting COVID-19 and seeing firsthand that climate change and the pandemic disproportionately impacts vulnerable communities.

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Larry Moore

H E A LT H C A R E A N D THE ENVIRONMENT

Unquestionably, the most challenging part has been knowing where to start and then how to set not just well-meaning goals, but also to take action. In 2019, Providence leaders considered several approaches toward our climate action commitment. First, we examined a range of improvement and adjustment opportunities, including addressing the emissions associated with our electricity, energy and greenhouse gasses individually. In addition, we reviewed the span of our commitment. We considered addressing emissions from our 52 acute sites only, all our clinical sites (hospitals, ambulatory centers, home health programs, virtual health services) or from all aspects of Providence, including office buildings, companies we have developed and investments. We recognized that to have a meaningful impact and set an example, we needed to include the entire organization.

WE ACT: A FRAMEWORK FOR ACTION

our efforts to reduce waste, choose lower carbonintensive foods and support local and sustainable foods. We believe we can decrease greenhouse gas emissions from our food services by purchasing foods that produce fewer greenhouse gases and by reducing waste during meal preparation and composting food waste. Chemicals: Our clinical work in anesthetic use has already resulted in a 50% emissions reduction (and millions of dollars saved) from inhaled anesthetics. We are developing best practices for nitrous oxide delivery and monitoring. We believe we can reduce these emissions by 90%. Transportation: Transportation is the largest contributor of greenhouse gases in the U.S. We are driving a more strategic and environmentally responsible approach to transportation. For example, we anticipate decreasing business travel emissions from a 2019 baseline by 50% by monitoring four aspects of business travel: flights, rental cars, hotels and reimbursed miles used in care delivery. We also are developing plans to electrify our fleet vehicles through purchase and

This carbon negative commitment will require cultural transformation across our organizations. These efforts are represented in the WE ACT strategic framework, which We educate and engage all outlines five focus areas: Waste, Energy/water, Agriculture/food, caregivers to take actionable Chemicals and Transportation. steps at their hospitals, clinics, Waste: Our goal is to send less than 50% of total waste to landfills or warehouses and other properties. incineration by 2030. We are actively conducting a waste optimization process to ensure that all sites send their waste lease. We plan to decrease emissions from cominto the correct disposal pathways. This focus muting by 30% by supporting remote-work initiaincludes the efforts to continually maximize recy- tives and alternative forms of commuting. cling, composting and source reduction of waste. Energy/water: We are maximizing the energy COLLABORATION AT EVERY LEVEL efficiency and minimizing water intensity of our We have worked hard to integrate this initiative buildings through conservation. Our infrastruc- into every facet of Providence, from grassrootsture investment will include modernization of engaged caregivers to executive leaders. Our existing buildings and design of new buildings. Environmental Justice Collaborative develops The opportunity includes the reduction of green- action plans to address the connection between house gas emissions from electricity by 96%, with the environment and health equity. Our Action more energy-efficient operations using renew- Collaborative for Environmental Stewardship is able electricity sources. As the core of our mission a system-wide group that shares best practices is to serve the poor and vulnerable, many areas we and tracks metrics and outcomes to advance our serve are at risk for water supply shortages. We efforts. developed a water reduction plan that incorpoWe educate and engage all caregivers to take rates low-water landscapes, low-flow fixtures and actionable steps at their hospitals, clinics, warewater-saving technologies. houses and other properties. Caregivers also are Agriculture/food: We have contracted with involved in Green Teams, groups of volunteers a large third-party vendor who is committed to who advance environmental stewardship efforts

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We have a responsibility to advance our healing ministry through care for our common home, on behalf of our patients and our communities.

using the WE ACT framework as a guide. In addition, we are working with key vendors to understand emissions from the products they manufacture, sell or deliver. All new construction projects will be designed to estimate and reduce embodied carbon in buildings (greenhouse gases emitted from manufacturing, transportation and construction of building materials).4

at the local level to address the WE ACT elements. In the spirit of the Sisters of Providence, we also partner with other health systems to educate them as they develop sound stewardship practices. We are proud that many have adopted our approach across their organizations to achieve similar results.

PRIORITIZING PATIENTS AND THE PLANET

MEASURE, TRACK, FOCUS

Our voice is always aimed at relieving injustices, especially for the poor and vulnerable. To better understand and reduce the impacts of climate change on vulnerable populations, we need access to complex data to track progress and measure outcomes. Our program’s effectiveness depends on access to reliable cost and consumption data. To that end, we are building the “WE ACT Data Scorecard” to bring insights to ministry leaders. This scorecard incorporates vendor reports and other data from each of the WE ACT categories. This database generates a monthly update of use, cost and carbon footprint for each acute care hospital. To identify where to focus efforts, we measure and track many elements of our operations to meet benchmarks for improved performance. We examine issues in the communities and regions we serve, along with current solutions that may be in place. By cross-referencing health risks with available resources, we can identify where we can help. Supply chain and procurement patterns drive a substantial amount of our estimated carbon footprint (38.4%). To tackle the challenge of decreasing emissions from procurement, we have developed an environmentally preferred purchasing policy. This system-wide policy instructs leaders across the organization to consider the environmental impacts of their purchasing decisions,

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Transformation does not happen overnight. Our 10-year plan keeps us moving forward. We face the same competing priorities and financial pressures that ministries across this country face. No matter the challenges ahead, environmental stewardship remains a top focus. This requires persistence, commitment and teamwork. We have a responsibility to advance our healing ministry through care for our common home, on behalf of our patients and our communities. We support others engaged in this work, because we know that complacency is not an option. ALI SANTORE serves as chief advocacy officer for Providence, Renton, Washington.

NOTES 1. Wenjia Cai et al., “The 2020 China Report of the Lancet Countdown on Health and Climate Change,” The Lancet Public Health 6, no. 1 (January 1, 2021): 64–81, https://www.thelancet.com/journals/lanpub/article/ PIIS2468-2667(20)30256-5/fulltext. 2. Matthew J. Eckelman et al., “Health Care Pollution And Public Health Damage in The United States: An Update: Study Examines Health Care Pollution and Public Health Damage in the United States,” Health Affairs 39, no. 12 (December 1, 2020): 2071–79, https://www. healthaffairs.org/doi/10.1377/hlthaff.2020.01247. 3. D.R. Reidmiller et al., eds., “Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II,” U.S. Global Change Research Program, 2018, https://nca2018.globalchange.gov. 4. Henry Siegel and Larry Strain, “Embodied Carbon: What You Can Do Right Now,” AIA California, March 5, 2020, https://aiacalifornia.org/embodied-carbondefinitions-and-facts/.

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CATHOLICS AROUND THE GLOBE CAN JOIN

Laudato Si’ Action Platform This fall, Catholics from around the world can

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make a public commitment to act on the urgent issues facing the environment. This commitment can be made through the Laudato Si’ Action Platform, which debuted in May with Pope Francis inviting

A Shared Statement of Identity for the Catholic Health Ministry We are the people of Catholic health care, a ministry of the church

continuing Jesus’ mission of love and healing today. As provider, employer, advocate, citizen — bringing together people of diverse faiths and backgrounds — our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit. We work to bring alive the Gospel vision of justice and peace. We answer God’s call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved, and most vulnerable. By our service, we strive to transform hurt into hope. AS THE CHURCH’S MINISTRY OF HEALTH CARE, WE COMMIT TO:

romote and Defend Human P Dignity ! Attend to the Whole Person ! Care for Poor and Vulnerable Persons ! Promote the Common Good ! Act on Behalf of Justice ! Steward Resources ! Act in Communion with the Church !

all Catholics on a journey “to create the future we want: a more inclusive, fraternal, peaceful and sustainable world.” The Laudato Si’ Action Platform was announced in May 2020 by the Vatican’s Dicastery for Promoting Integral Human Development as part of the Laudato Si’ Special Anniversary Year. The goals of the action platform reflect the encyclical’s recognition that long-term solutions to the climate crisis need to address the environmental, economic, political, social, cultural and ethical issues that drive overconsumption, wastefulness and pursuit of profits without regard to human or environmental costs. The seven goals of the action platform are: Response to the Cry of the Earth Response to the Cry of the Poor Ecological Economics Adoption of Sustainable Lifestyles Ecological Education Ecological Spirituality Community Involvement and Participatory Action The platform will provide customized planning guides, resources and community support to help seven target sectors achieve action platform goals over seven years: families; parishes and dioceses; schools and universities; hospitals and health care centers; businesses and farms; lay movements and organizations; and religious congregations. Pope Francis has said he hopes “we can all collaborate, each with their own culture and experience, each with their own initiatives and abilities, so that our mother Earth returns to its original beauty and creation again shines according to God’s plan.” For more about the Laudato Si’ Action Platform:

https://laudatosiactionplatform.org/

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WATER, SANITATION and HYGIENE

Vatican, Catholic Health Care Take Leadership Roles in ‘WASH’ Work SUSAN K. BARNETT Founder of Faiths for Safe Water

recently had surgery to restore some hearing loss. It was an outpatient procedure but required general anesthesia. Though I found myself in post-op recovery at a top hospital in New York City, where I live, the picture I couldn’t get out of my mind was of something quite different. I work on issues of access to water and sanitation and as I felt my fresh sheets and took notice of the clean bathrooms and persistent handwashing by staff, I couldn’t help but revisit the hospitals and health clinics I’ve seen where clean and safe health care is impossible. I’ve seen donkeys making 20 trips a day, carting water from a river where animals drink and defecate, to a rural hospital in Ethiopia because that is the only water source. I won’t forget the small pink bucket that was one half of a health center’s entire “water system” in rural Nepal. In an area endemic for typhoid and malaria, I’ve watched medical staff forced to go outside to wash their hands in water containers that are a breeding ground for disease-carrying mosquitoes. I’ve seen more broken faucets and sinks than I can count, open defecation on health care facility property due to the lack of functional toilets and outhouses, and waste pits filled to the brim with all manner of medical waste. This problem is widespread across low- and middle-income countries. According to the 2020 WHO/UNICEF Global Progress Report, one in four health care facilities worldwide lacks adequate water, sanitation and hygiene (WASH).1

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Isolating the 47 low-resource countries, 50% of health care facilities lack water on site, and sanitation is even worse, with 63% of facilities failing to provide adequate toilets. Doctors and nurses working at 30% of these health care facilities cannot wash their hands at points of patient care. Nearly 2 billion people rely on these facilities, which cannot comply with the most basic safe care standards. The lack of access to clean water, toilets, hygiene and waste management in health care facilities is its own kind of global health pandemic. Quality health care is impossible without WASH, and poor-quality health care is costly. Lost productivity totals $1.4 to $1.6 trillion per year.2 The human costs are incalculable: Infection prevention control is impossible. Antibiotic resistance increases worldwide. Response to COVID-19 has been deficient, and Ebola has killed medical staff in tragically high numbers.

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THE DEVASTATING SCOPE OF THE PROBLEM

ernment hospital that serves more than 250,000 people. He was initially pleased when he saw a functional waste management system hooked up to the municipal sewer system. But when the staff told him they had no idea where the sewer went, he feared he’d seen this situation before. He found the municipal wastewater dumping into a river nearby, and later that day, he found himself slamming on his brakes to intervene when he saw a water tanker filling up with that river water downstream from the hospital. The most shocking WASH conditions are often found in labor and delivery areas where life takes

Haik Kocharian for Village Health Partnership

Faith-based organizations are critical to global health. Around the world, faith-based networks provide health care where there might otherwise be none, operating without discrimination to religion or nationality. Yet far too often, faith-based facilities also operate without WASH. The reasons for the lack of WASH share common themes. Sometimes the problem is the absence of infrastructure or infrastructure that was never completed; sometimes infrastructure is crumbling due to the lack of training and maintenance; often there’s no budget, and staff do the best they can. With good intentions, faith communities and nonprofits have sometimes delivered wells and pumps without a plan to maintain them after they leave. As the single largest unified source of health care worldwide, the Catholic Church’s interest in WASH can be transformative. The Vatican has taken notice, and has launched an important pilot project to assess WASH in Catholic-run health care facilities in low-resource areas. In undertaking this initiative, it opened up a looming question: What does the WASH situation in these facilities look like?

Two donkeys make 20 trips a day to transport water from a dirty stream

Examples of the challenges where animals drink and people bathe to a health care facility in Ethiopia. health systems face without WASH abound, and Mike Paddock, former chief engineer for Engi- its first breath. Millions of women must actually neers Without Borders-USA, has seen plenty of haul their own water to give birth in dirty and often them.3 “I will never forget the day,” Paddock once overcrowded maternity wards. In some cultures, told me, “that I had to inform a hospital direc- newborns are not named because early death is tor that his wastewater system was the cause of so commonplace. When I was traveling in Ethiothe typhoid outbreak he was desperately fighting. pia, I heard stories from so many women who had lost a child during childbirth that (I’m ashamed to You can’t imagine the agony on his face.” Paddock’s stories are hard to forget — he’s say) I caught myself reacting with surprise when a traveled the world leading humanitarian, WASH woman hadn’t lost a child. Try to wrap your head and infrastructure projects in some of the world’s around the fact that an unspeakable and rare tragmost remote, challenging and impoverished edy here is daily life there. Among the deadly causes are health careenvironments. For example, Paddock was asked to inspect WASH at a Guatemalan regional gov- associated infections (HAIs). Not surprising,

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Susan K. Barnett

newborn infections are three to 20 times higher grow to school age, more adults would be there to in resource-limited settings where infections care for their families, and more health care procan be transmitted by unwashed hands, con- viders would survive to serve in the next time of taminated beds, unsafe water and dirty instru- need,” says Sr. Mary Louise Stubbs, DC, executive ments used to cut umbilical cords.4 Nurses and director, Daughters of Charity International Projmidwives cannot adequately wash their hands ect Services. “Sisters around the world are true to keep themselves and their patients safe (even heroes who do not know they are being heroic; during COVID-19), and women cannot adequately they only know that they are needed to bring clean themselves after they give birth. Caring for health care to the sick, and they only know that post-partum hemorrhage and bleeding are impos- water is a rare treasure without which their work sible without water and sanitary pads. Toilets are is crippled.” routinely scarce, broken and filthy and the lack of waste management finds health care facilities lit- THE BEGINNINGS OF A SOLUTION tered with used menstrual products alongside all Chiapas, Mexico, an impoverished region that forms of contaminated medical and human waste. has seen its share of unrest, is the site of the San Moreover, poor WASH conditions stop pregnant Carlos Hospital, established in 1969 and run by women from seeking maternity services in facili- the sisters since 1975. This busy rural hospital ties with trained staff, further undermining their reaches 349 communities, averaging 17,000 conhealth and the health of their sultations annually that cover child.5 outpatient visits and admissions, pediatrics, OB/GYN and interDay One is when more than nal medicine. It has a pharmacy, 40% of maternal and newoperating room, X-ray, ultrasound, born deaths occur, although a lab and it covers community the majority of these deaths health, too. Sr. Adela Orea, DC, the are preventable. More than 1 hospital’s energetic administramillion deaths each year are tor, recalls “a lot of anguish and a associated with unclean births, great burden” during her 37 years while infections account for of experience. “When there is no 26% of neonatal deaths and 11% hygiene, when there are no condiof maternal mortality. Contrast tions to test for sepsis and asepthat with handwashing and sis in hospitals, this can become a clean birthing practices: when focus of infection. And instead of in place, newborn survival rates This pink pail serves as a water providing health, we succumb to increase up to 44%.6-9 source for a health clinic in infections and disease.” Nepal. Water and sanitation The facility’s early water situWITH BETTER HYGIENE improvements are beginning ation required pumping water of RESOURCES, MORE WOULD at health care facilities in poor quality from the nearby river. SURVIVE To say that the Daughters of dozens of countries, but greater Water for drinking and sanitation was upgraded with access to a Charity of St. Vincent de Paul prioritization and budgets are have seen it all is almost an needed for sustainable progress. spring, but as the region’s population grew, residents needed water, understatement. Since their founding in 1633, the order has provided health too, and tapped into the hospital’s waterline for care in the streets, in villages and in hospitals, household needs. As a result, the demand on the wherever the need was urgent and the resources spring grew far greater than the amount of water scarce. Today, many sisters are highly trained phy- it could produce, and the spring’s pump became sicians, nurses and ancillary professionals. But costly to maintain. The sisters sought a solution. no medical professional can compensate for the Collaborating with Water Engineers for the Amerlack of water and sanitation systems that plague icas and Africa, a professional volunteer organization, and with local government cooperation, facilities. “If they had these basics, more babies would they were able to get a new storage tank and pipes, survive their first month, more children would which also accommodates community needs.10

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THE VATICAN RESPONSE

Haik Kocharian for Village Health Partnership

Answering a moral call, the Vatican launched a landmark initiative in 2020 to improve WASH in the health care facilities it runs, led by the Dicastery for Promoting Integral Human Development, under its prefect, Cardinal Peter K.A. Turkson.12 The Vatican focus on this global issue provides important leadership and influence, and will lead to safer care for millions of people. The dicastery first drew attention to the lack of WASH A maternity room in Ethiopia lacks access to clean water, needed for in health care settings in its patient safety and dignity. 2018 World Water Day communique, “Aqua Fons Vitae.”13 Similarly, the Uganda Catholic Medical Then, in his letter of August 2020 to Catholic Bureau 11 conducted WASH assessments of Bishops’ Conferences worldwide, Cardinal Turk14 health care facilities in the Tororo Archdiocese son called for WASH, “in order to safely treat in 2017-2018 and subsequently procured 43 hand- patients, prevent further spread of COVID-19 and washing facilities, several water storage tanks other diseases, and protect health care workers and posted hand hygiene and safe waste segre- and chaplains who are doing God’s work by cargation information for staff. (Well-timed given a ing for the sick.” His letter invited each bishop to global pandemic was to break out.) Some facil- voluntarily take part in an effort to ensure proper ity managers went further, renovating toilets and WASH standards with infrastructure, equipment, bathrooms, constructing incinerators, organiz- maintenance and staff training at all health care ing refresher hygiene training and reconsidering facilities within their dioceses. facility design to accommodate people with disabilities. The Uganda Catholic Medical Bureau disseminated assessment findings to bishops “Every day, unsafe water to raise awareness and support for subsequent results in many deaths and WASH in health care facility projects in Uganda. The organization also worked with Engineers the spread of water-related Without Borders to bring water to the Dabani Hospital in the Tororo Diocese. This facility diseases, including those offers care to nearly 26,000 people across 52 villages. Rather than paying someone to fetch caused by microorganisms water, water is now piped into all wards, which and chemical substances. increases handwashing and infection prevention control. Infection rates are anticipated to drop. Dysentery and cholera, The hospital project also extended water access linked to inadequate hygiene to the community and neighboring primary school. Dedicated cost-sharing will help ensure and water supplies, are a operations and maintenance. And here’s the thing: These relatively uncom- significant cause of suffering plex examples illustrate that the problem of a lack and of infant mortality.” of WASH in health care facilities is solvable. But it is a systems issue and must be addressed as such. — POPE FRANCIS, Laudato Si’ (2015)

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The reaction was massive, reflecting the need. Bishops in 23 countries responded. The dicastery subsequently completed WASH assessments in 151 pilot facilities across the 23 countries. These facilities serve areas encompassing some 28 million people. Assessments were carried out by the hospitals and clinics, trained by Catholic Relief Services, Caritas Internationalis and Global Water 2020, in coordination with the Dicastery.14-16 Each facility received a report that identified its strengths and gaps, and was encouraged to start incremental improvements that require no or minimal funding. Private and public sector partners and donors are being sought to mitigate the larger WASH needs. Once funding for a specific health care facility or facilities is identified, full technical studies will be completed and available to the donor with multiple routes for donor engagement. Importantly, each health care facility and

implementing organization is committed to ensuring that sustainability is built-in from the start, with 5% of costs dedicated to ongoing maintenance and repair. Inevitably, pipes, wells, water tanks, sinks, toilets and more break, especially when they’ve not been maintained for years, if not decades, due to the lack of funds, training, supplies and neglect. While the Dicastery itself will limit its role to seeking funding for the initial 151 pilot health care facilities, this effort is the starting line, not the finish line, for Catholic facilities. Sr. Gina Marie Blunck, SND, is executive director of the Conrad N. Hilton Fund for Sisters, established in 1986 to support the ministries of Roman Catholic sisters. Access to safe drinking water is one of the fund’s health priorities, and each year at least 10% of its projects provide water to a facility and surrounding community. Sr. Blunck not only commends the Dicastery’s efforts to identify WASH-needy facilities globally, she says the

Catholic facilities do not escape the poor WASH conditions endemic in low-resource settings around the world. Assessments in 151 facilities in 23 countries found:

SANITATION 76% do not have toilets available for people with limited mobility.

WATER

74% lack menstrual hygiene management facilities like waste bins and private space.

56% have their main water point located off premises.

59% do not treat their water, which

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often comes from unsafe sources.

27% that provide birthing services lack water in the delivery room, and 15% expect women to bring their own water to deliver some or all of the time. 15% did not have water on the day of the survey, and 26% go without water at least once a week.

14% do not have any hand hygiene materials in the wards; 52% do not have soap and water near all toilets. BUDGET

Nearly half of the facilities do not have a line-item budget for WASH.

Information from WASH assessments, see also: https://www.humandevelopment.va/content/dam/sviluppoumano/progetti/wash-2021/Summary-Handout.pdf

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fund “will select facilities owned and operated by a congregation of sisters and provide funding in collaboration with others. The Fund for Sisters is anxious to participate in this collaborative, which will benefit the sisters and address the health, sanitation and hygiene of those they serve.”

GLOBAL MOMENTUM IS GROWING

The Vatican initiative is well-aligned with Catholic teaching and global need. “Catholics work hard for human rights,” Sr. Orea reminds us from her facility in Chiapas. “The right to health is one of the most inalienable rights of the human being. Whoever has water, has life.” Though the Vatican’s engagement is particularly significant due to the Church’s vast global reach, neither the Vatican nor the sisters are alone among faith-inspired efforts to get WASH in health care facilities. Noteworthy work is also being undertaken by organizations such as World Vision, Nazarene Compassionate Ministries and the Aga Khan Development Network, among others. United Nations entities are also increasingly prioritizing this issue with country-led engagement, roadmaps and standards.17 In addition, the U.S. Agency for International Development (USAID) is working to increase its partnerships with a diverse faith community. Rev. Adam Phillips leads USAID’s Center for Faith-Based and Neighborhood Partnerships and USAID’s Local, Faith and Transformative Partnerships Hub. Phillips appreciates that faith-based organizations have “long-standing connections with hospitals, clinics, local leadership and communities [that] have made them the go-to resource for information, basic needs and emotional and spiritual support.” He describes the need for diverse stakeholders to improve WASH in health care “to ensure quality of care, dignified environments and improved well-being for everyone who walks through the doors.” Those stakeholders need to include leadership by ministries of health and other ministries, and service providers that include faith-based organizations, as well as local governments, the private sector and communities. CHA also assists by raising the profile and discussion of WASH among its network of U.S. health providers that offer international support. It has a history of supporting efforts in Haiti post-earthquake, and will do so again by sup-

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porting the inclusion and maintenance of muchneeded WASH in 10 health care facilities that each serve multiple communities throughout all 10 departments in Haiti. With growing momentum, faith-based, secular and government institutions that provide health care are finally beginning to see that tackling this solvable problem is a foundational route to the hope, dignity and healing that health care is meant to provide. Health care for all can be what I experienced. As I started to stir after my surgery, a kind nurse came over with a welcome offer: a cup of cool clean water, which I accepted with perhaps extra gratefulness that came from these scenes I replayed in my mind.

FOR MORE INFORMATION Vatican WASH in Health Care Facilities Initiative: water@humandevelopment.va Sr. Mary Louise Stubbs, DC, Executive Director, Daughters of Charity International Project Services: marylouise.stubbs@doc.org World Health Organization WASH in health care facilities resources: www.washinhcf.org Bruce Compton, Senior Director, Global Health, Catholic Health Association of the United States: bcompton@chausa.org SUSAN K. BARNETT is founder of Faiths for

Safe Water and part of the Global Water 2020 initiative, which focused on underrepresented issues of global water health and security. She was a journalist with the network newsmagazines PrimeTime Live, 20/20 (ABC News) and Dateline NBC. She now leads Cause Communications. For more, see www.faithsforsafewater.org/.

NOTES 1. “Global Progress Report on WASH in Health Care Facilities: Fundamentals First,” World Health Organization, https://www.who.int/publications/i/ item/9789240017542. 2. “Crossing the Global Quality Chasm: Improving Health Care Worldwide,” National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/ NBK535654/. 3. Engineers Without Borders, https://www.ewb-usa. org/.

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4. Anita K. M. Zaidi et al., “Hospital-Acquired Neonatal Infections in Developing Countries,” The Lancet 365, no. 9465 (26 March–1 April 2005): 1175-1188, https://doi.org/10.1016/S0140-6736(05)71881-X. 5. Maha Bouzid, Oliver Cumming and Paul R. Hunter, “What is the Impact of Water, Sanitation and Hygiene in Healthcare Facilities on Care Seeking Behaviour and Patient Satisfaction? A Systematic Review of the Evidence from LowIncome and Middle-Income Countries,” BMJ Global Health 3, no. 3 (2018), https://doi.org/10.1136/ bmjgh-2017-000648. 6. Dr. Zulfiqar A. Bhutta, “Integrated Strategies to Address Maternal and Child Health and Survival in Low-Income Settings: Implications for Haiti,” Permanente Journal 20, no. 2 (Spring 2016): 94-95, https://doi.org/10.7812/TPP/15-204. 7. “Water, Sanitation and Hygiene,” United Nations, https://www.unwater.org/water-facts/ water-sanitation-and-hygiene/. 8. “Water, Sanitation and Hygiene in Health Care Facilities: Practical Steps to Achieve Universal Access to Quality Care,” World Health Organization, https://apps.who.int/iris/bitstream/handle/10665/ 311618/9789241515511-eng.pdf. 9. Victor Rhee et al., “Maternal and Birth Attendant Hand Washing and Neonatal Mortality in Southern Nepal,” Archives of Pediatrics and Adolescent Medicine 162, no. 7 (2008): 603–608, https://jhu.pure.elsevier.com/en/publications/ maternal-and-birth-attendant-handwashing-and-neonatal-mortality--4. 10. Water Engineers for the Americas and Africa, https://www.wefta.net/. 11. Uganda Catholic Medical Bureau, https://www. ucmb.co.ug/. 12. “WASH Conditions in Catholic Health Facilities,” Dicastery for Promoting Integral Human Development, https://www.humandevelopment.va/en/ news/2021/wash-conditions-in-catholic-healthfacilities.html. 13. “Aqua Fons Vitae,” Dicastery for Promoting Integral Human Development, https://www. humandevelopment.va/en/risorse/documenti/ aqua-fons-vitae-the-newdocument-of-the-dicastery-now-available.html. 14. Catholic Relief Services, https://www.crs.org/. 15. Caritas Internationalis, https://www.caritas. org/. 16. Global Water 2020, http://globalwater2020.org/ index.html. 17. “Fundamentals First.”

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Global Health Meditative Reflections

In partnership with Carter Center and Center for Compassionate Leadership meditative experts, this series of reflections will help you build resiliency, focus on global health topics and increase well-being.

Go to chausa.org/international to access these new resources!

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How Can We Turn To the Healing Power of Nature? CHRISTINA LEAÑO, MA Associate Director, Laudato Si’ Movement

“T

he virus is everywhere: my blood, my lungs, my stomach,” my husband weakly croaked through the phone from his hospital bed in Manhattan. I imagined the virus to be like the Blob from the 1950s movie: dark, invasive and taking over everything in its path.

My chest weakened in disbelief. Just 15 hours earlier, we were making home improvement plans in his hospital room. Now, there was a virus giving him a 104 degree fever and taking over his poor vulnerable body. This was just one of the many twists and turns of the journey we had been on since his life-long lung condition deteriorated a few years ago. One of the most significant landmarks had been a double lung transplant he received just a year ago. It was a roller coaster ride of ups (YES! A set of matching lungs for a transplant!) and downs (What, lymphoma?). Just days earlier, my 36-yearold husband had come home after finishing his third round of chemotherapy. When his temperature spiked a few hours later, we rushed him to the hospital. I put the phone down and took a couple deep breaths before joining a Zoom meeting I was already late for. During the meeting, I focused on staring at the boxes of people, breathing deeply into my belly. As the meeting was coming to a close, the meeting chair softened her voice and

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asked, “Christina, how is your husband? We prayed for you all at the beginning.” Her question cracked the fragile shell I had been attempting to keep together. A rush of tears broke through. I was simultaneously embarrassed and touched by her compassion. After the call, my manager, who had been part of the call, sent me a message over Slack encouraging me to take time off, to give myself space. My initial reaction was to respond that I was OK, that work was actually a welcome distraction. By some act of grace, I recalled my recent training to become a Mindful Self-Compassion teacher. Developed by psychologists Kristin Neff and Christopher Germer, self-compassion is the invitation to offer compassion to oneself as you would to a friend or to another person who might be suffering. As an act of “soothing touch,” I placed my hand on my heart and asked the ultimate question one is to ask oneself when experiencing suffering or pain: “What do I need right now?” I stopped and listened. And what my heart said was, “Get the

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heck out of here.” An image of myself biking along of a quote from Pope Francis’ encyclical Laudato the water’s edge popped into my mind. Nature, Si’: “The entire material universe speaks of God’s love, his boundless affection for us. Soil, water, healer and guide, was beckoning. So often in my life, nature has been a solace, mountains: everything is, as it were, a caress of a place of refuge in times of distress. The heal- God.”2 I felt caressed by God. At this moment, I ing power of nature is something instinctual to felt invited to rest in this affection and receive the many of us. Indigenous cultures have long main- ultimate compassion. tained a holistic relationship with nature as part of In Laudato Si’, Francis also shares the wisdom well-being and wholeness. Now, emerging prac- that is imparted through creation: “This contemtices such as the Japanese meditative exercise of plation of creation allows us to discover in each Shinrin-yoku, or “forest bathing,” are renewing thing a teaching which God wishes to hand on to this relationship with nature to support mental us.”3 As I continued to bike, I could feel my perand physical health. In forest bathing, one is invited to immerse oneself So often in my life, nature has been a in nature by taking in one’s surroundings with one’s physical senses, to live solace, a place of refuge in times of in the present moment. A growing distress. The healing power of nature number of studies validate the positive impact that forest bathing can is something instinctual to many have on the nervous system, blood pressure and other health indicators.1 of us. I cancelled my three scheduled meetings and went downstairs to get my bicycle spective widening. On my left, I saw patches of out of the basement. After about 15 minutes, I was berries producing their summer crop. On my on the path along the Hudson River at Nyack Beach right, five snowy mute swans were swimming State Park. The gravel path crunched beneath my parallel to the shore. The sun was flitting through bicycle tires as I sped along the water’s edge. The the shimmering leaves of the trees. I was slowly red cliffs of Hook Mountain towered to my left. On opening up to other rhythms of life beyond my own circumstances. I was reminded that life was the right, the river was still. Several years ago, I participated in a “forest so much bigger than my personal universe. And death was a natural part as well. Up ahead, bathing walk” in Harvard University’s Arnold Arboretum in Boston. One of the practices was to I saw a turkey vulture bending over some hidden experience one’s surroundings using each of the carrion. It flew away as I approached, leaving five senses. Connecting with the physical senses behind the acrid stench of its meal. I smelled the is a way to shift the attention from the thinking reminder of death that is part of the natural cycle. mind to the feeling body. How many of us have There are comings and goings that I do not need found ourselves in the middle of a gorgeous land- to push against. I reached the base of a hill, where trees shaded scape, only to be focused on a worry or problem in the mind? The practice of forest bathing the shore, and a few picnic benches were scattered invites the practitioner to experience the present on the small beach. There was a man with a young moment in nature by transitioning from “doing” girl, perhaps his daughter, who had also biked mode to “being” mode. It is a chance to step off the here, eating their lunch. I felt the healing effects hamster wheel of our often overactive mind and, of nature therapy. I was ready to turn around and head back home. literally, take a breath of fresh air. Some doctors have begun to recognize the As I was biking, I allowed myself to do the same. I focused on the sun’s fiery heat on my skin, healing benefits of being outdoors. In her blog the wind rushing through my hair and past my post “The Coronavirus is Heading Your Way. Grab face, and the soft earth below me. I slowly felt the a Tree and Hold On,” Dr. Suzanne Bartlett Hackrawness of the morning softening as the elements enmiller says, “I prescribe nature to my patients surrounded and immersed me. I was reminded on a daily basis. … Even Hippocrates said, ‘Nature

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itself is the best physician.’” She shares that being in nature does not have to include a long hike in the woods. Some studies have demonstrated health benefits arising from connecting with natural elements in our everyday life, a tree outside our window, a potted plant, even nature-themed artwork. “All these actions are likely to improve immune function either directly or indirectly.”4 I have even found that just imagining a place in nature can bring solace. I recently participated in a meditation in which I was invited to bring to mind a special place in nature inspired by a quote from Laudato Si’: “The history of our friendship with God is always linked to particular places which take on an intensely personal meaning ... revisiting those memories does us much good … [It] is a chance to recover something of their true selves.”5 Immediately the sandy beaches of St. Augustine, Florida, near the place I grew up, emerged in my imagination. I began to feel the warm sand beneath my toes, the salty breeze blowing on my skin, in my hair. Nearby, seagulls were squawk-

ing. My body began to relax and settle. As I gazed at the ocean, I saw the shimmering light on the water. The sea was rising to meet me. And then it fell away. I became mesmerized by this rhythm of the ebb and the flow, the approach and the departure. As the sea receded, I could feel my breath shorten, as if I was not ready for the loss of departure. I thought of my and my husband’s situation, the rhythms and changes beyond my control. I often am asking, “Are things getting better or getting worse? Coming in or receding?” The sea’s movements seemed to remind me of how natural this ebb and flow were. They are but different moments and the same. I followed this pattern of the sea for a few more cycles, feeling the invitation to not change it, but just ride it. Can I allow them to just be? Here on the edge of the Hudson River, I felt again the same invitation: Can I just allow things to be? This illness, my grief, the gift of our relationship and family, this moment? Can I allow them to come and go? This is as much a part of life

MEDITATION: PRAYING WITH CREATION THROUGH THE IMAGINATION

n Laudato Si’, Pope Francis shares, “The history of our friendship with God is always linked to particular places which take on an intensely personal meaning; we all remember places, and revisiting those memories does us much good.” Here is a meditation to help you pray with creation using the imagination: Enter into a time of prayer — perhaps closing your eyes, noticing your feet on the ground, being held by the earth, and taking a few deep breaths to ground yourself in this moment of prayer. Offer a prayer to be open to God’s presence in the gift of creation. Bring to mind a place in nature that is meaningful to you. It can be a place from childhood, a place visited during a special trip, in your neighborhood, or maybe somewhere you’ve never been, but has significance to you. Imagine the place as vividly as possible, as if you are there right now. Notice the colors. The textures. The different shapes. What are you hearing? Smelling? Touching? Notice how you feel in

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this place. See if you can name those feelings, allowing yourself to relax further into any feelings of safety, comfort and peace. “[T]o contemplate creation is to hear a message, to listen to a paradoxical and silent voice.”1 As you imagine yourself in this special place, ask if there is a message God is sharing with you at this time. Perhaps you have a question or something you would like to bring into prayer. Just notice if anything arises, not worrying if you do not hear anything. Just open yourself to hear the message of creation. When you are ready, close by offering a prayer of thanks to God for the gift of creation and whatever message you may have received at this time.

NOTE 1. Pope Francis, Laudato Si’, paragraph 84, https:// www.vatican.va/content/francesco/en/encyclicals/ documents/papa-francesco_20150524_enciclicalaudato-si.html.

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as the berries, the carrion, the seas and the beauty. As I bike back home, I think of how my conditions have and have not changed. My husband is still sick in the hospital, but my relationship to my present moment has transformed. I remember something I heard in an interview with Benedictine monk Br. David Steindl-Rast, OSB: “… not for everything that’s given to you can you really be grateful. You can’t be grateful for war in a given situation, or violence, or sickness, things like that. So the key, when people ask, ‘Can you be grateful for everything?’ — no, not for everything, but in every moment.”6 At this moment I feel grateful. Not for my husband’s illness, but for this moment of finding my grounding again in the beauty and wisdom of nature. “Nature is filled with words of love,” Francis reminds us in his encyclical.7 In this moment, these words of love I have heard in nature give me the strength to move forward with a lightness and confidence, despite the uncertainty. I am held in the rhythms of life. CHRISTINA LEAÑO is associate director of the Laudato Si’ Movement, Hastings-On-Hudson, New York. She also is a meditation teacher and retreat leader.

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NOTES 1. Bum Jin Park et al., “The Physiological Effects of Shinrin-Yoku (taking in the forest atmosphere or forest bathing): Evidence from Field Experiments in 24 Forests across Japan,” Environmental Health and Preventive Medicine 15, no. 1 (May 2, 2009): 18-26, https://dx.doi. org/10.1007/s12199-009-0086-9. 2. Francis, Laudato Si’, paragraph 84, https://www. vatican.va/content/francesco/en/encyclicals/ documents/papa-francesco_20150524_enciclicalaudato-si.html. 3. Francis, Laudato Si’ paragraph 85. 4. Suzanne Bartlett Hackenmiller, “The Coronavirus is Heading Your Way. Grab a Tree and Hold On,” Integrative Initiative, February 29, 2020, https://integrative initiative.com/2020/02/29/the-coronavirus-is-headingyour-way-grab-a-tree-and-hold-on/. 5. Francis, Laudato Si’ paragraph 84. 6. Interview with David Steindl-Rast, “How to Be Grateful in Every Moment (But Not for Everything),” On Being with Krista Tippett, original airdate January 21, 2016, https://onbeing.org/programs/david-steindl-rast-howto-be-grateful-in-every-moment/. 7. Francis, Laudato Si’ paragraph 225.

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Medical Professionalism And Racial Inequity MYLES N. SHEEHAN, SJ, MD Director of the Edmund D. Pellegrino Center for Clinical Bioethics at Georgetown University

he last 18 months have been filled with concurrent crises. The COVID-19 pandemic has been an exceptional stress on our American health care system, stretching hospitals, physicians, nurses and all health care providers to, and sometimes beyond, their limits. The death toll in excess of 650,000 has been awful in itself, but the evidence of poor outcomes for minorities and those with low incomes demonstrates in stark fashion the inequities that appear to be inherent in American health care. Along with the pandemic, the death of George Floyd, killed under a police officer’s knee, and other police-related deaths of people of color brought to the fore issues of racism, injustice and structural inequality in our society. The response of health care professionals to the sick and suffering in the coronavirus pandemic exemplified some of the best of professionalism: dedicated service at personal risk and enduring long hours to care for the critically ill. But revelations about health disparities, not only related to deaths from COVID but also other issues like maternal mortality of Black women, raise the question as to whether medicine as a profession is part of the problem of structural injustice and inequity in health care. As a physician, I am targeting the profession of medicine and arguing that focusing on health equity, improved minority representation in the profession and dismantling structures that contribute to injustice in health care are crucial to a reconsideration of the practice of medicine. I believe this is likely true of other health care fields but feel it is best for me to comment on my own profession. The medical profession should be a powerful force for change. Reviewing recent notions of medical professionalism reveal that a focus on positive change is inherent for individual physicians and the profession as a whole. Physicians need the support of Catholic health care systems and local hospitals to create positive change that reduces inequity and racism while improving health care outcomes for minorities.

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MODELS OF MEDICINE AS A PROFESSION

Study of the profession of medicine prior to the 1990s focused more on the sociological characteristics of the profession rather than moral commitments. The classic work was Eliot Freidson’s Profession of Medicine: A Study of the Sociology of Applied Knowledge, published originally in 1970 but incorporating previous work done by the author. Freidson characterized medicine as a profession defined by four characteristics: 1) those entering the profession underwent extensive and arduous training; 2) this training brought to physicians specialized knowledge and skills of great benefit to society by maintaining health, curing disease when possible and limiting suffering for members of the society; 3) as a consequence of the benefits to society, members of the profession are granted considerable professional autonomy; and 4) that autonomy comes with a set of societal obligations. Those obligations included acting in the patient’s best interests, maintaining confidentiality (with rare legally mandated exceptions), a commitment to competence and skilled service, responsibility to the patient before personal interests, financial honesty and professional selfregulation.1 The final decade of the 20th century brought renewed interest in considering the role of phy-

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sicians and the profession in response to several pressures. Those pressures included the introduction of managed care, the development of for-profit health care corporations and concerns about physician behavior. Managed care contracts raised potential conflicts between the needs of the patient and the financial reimbursement of physicians who were rewarded for limiting expenses. For-profit health care treats the medical management of persons as a commodity and, like managed care arrangements, unsettles traditional values of putting the treatment of vulnerable people above financial concerns. Finally, there was increased attention on physicians who made sexist and harassing comments, displayed racist attitudes and behaviors, threw temper tantrums and made insulting remarks to nurses, medical students and other staff. A number of voices presented a vision for the profession of medicine in response to these challenges. I will focus on three: the work of Dr. Edmund Pellegrino, a groundbreaking article by Matthew Wynia and others in the New England Journal of Medicine, and an address by Cardinal Joseph Bernardin to the American Medical Association House of Delegates. Pellegrino was a physician, a scholar, one of the founders of American bioethics and the namesake of the bioethics center where I teach. He argued for an understanding of medicine as a distinct profession with an inherent moral core. An individual physician, by her or his oath of profession, formally promises dedicated service to the patient. The goal in every encounter is to find the right healing action in the relationship between the doctor and the patient. This right healing action is based on a four-fold good: the biomedical, the person’s own good, the person’s sense of her or his goods as a human being and the person’s spiritual goods. The doctor works with the patient, using the knowledge, skill, compassion and competence that are essential to the doctor’s role, in finding the right biomedical good that will accomplish the patient’s achievable goals of care. This is what it means to act beneficently, respecting the patient autonomy to bring about the best outcome possible.2 It is this dedicated care of and service to the patient that is the center of professionalism. As a group, physicians constitute a moral community by their oath of service and their daily practice. But the responsibility of this moral community both encompasses the individual doctor-patient

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encounter and extends broadly. Pellegrino writes: “Physicians cannot be indifferent to injustice, inequality and suffering caused by our system of health care, by an institution’s insurers, or by our professional self-interest. We share a collective responsibility to be strong and clear voices for a just health care system, for the competence of our fellow physicians for the rehabilitation or expulsion of those who violate the moral demands of what it means to be a physician.”3 Wynia and his colleagues, in their 1999 New England Journal of Medicine article, note that professions broadly have a societal function in protecting vulnerable persons and vulnerable societal values. They argue that medicine should be

This dedicated care of and service to the patient is the center of professionalism. As a group, physicians constitute a moral community by their oath of service and their daily practice. defined by distinct moral premises. Chief among them are: devotion to providing health care that places individual and public health ahead of selfinterest; a public profession of values that recognizes a shared understanding so patients can trust their physicians; and a willingness for professionals to be in dialogue with the public about shared values that are held by both the profession and the larger society. The model serves as a basis for trust for the public in the profession and a commitment by the profession to be accountable, put the patient over their own self-interest and be responsive to the needs of society in delivering health care.4 Cardinal Bernardin, like Pellegrino and Wynia, puts moral relationship at the heart of the medical profession. Bernardin’s reflections came in the wake of being diagnosed with pancreatic cancer and his own experience of illness. His model of the profession views medicine as a covenant between the patient and the physician, with the covenant based on moral obligations, and establishes

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responsibilities for the physician from this covenantal relationship. The moral obligations are to work to establish healing, to promote and restore wholeness of life and respond to those who ask for help. The individual responsibilities for physicians include putting the patient’s interests first, demonstrating real caring rather than simple technical expertise in the use of medical science and technology, upholding the sanctity and dignity of life from conception to natural death and attention to the physicians’ own spiritual needs as healers. In turn, the profession has three obligations to society: establishing health care as a basic human right, promoting public health in the widest possible sense and providing leadership on the protection of human life and the enhancement of human dignity while facing that health care resources are not unlimited.5 The sixth edition of the Ethical and Religious Directives for Catholic Health Care Services provides a description of the professional-patient relationship that corresponds to the models of Pellegrino, Wynia and Bernardin and extends it to the Catholic Church’s commitment to human dignity. The introduction to Part Three of the Ethical and Religious Directives states: “A person in need of health care and the professional health care provider who accepts that person as a patient enter into a relationship that requires, among other things, mutual respect, trust, honesty and appropriate confidentiality.” In Catholic health care, the professional-patient relationship is rooted in our Catholic faith and its teaching: “When the health care professional and the patient use institutional Catholic health care, they also accept its public commitment to the Church’s understanding of and witness to the dignity of the human person. … The faith that inspires Catholic health care guides medical decisions in ways that fully respect the dignity of the person and the relationship with the health care professional.”6 Revisiting medical professionalism in a time when we are becoming more aware of unjust outcomes, serious health disparities and inequity in access and care is crucial if the profession of medicine seeks to retain the moral core that has been highlighted in this article. This is true for the profession in general but is even stronger in Catholic health care, where the moral nature of

the profession is in service to the healing mission of Jesus Christ.

RESPONDING TO THE CRISIS

What are the implications for the profession of medicine when concerns about racism, inequity and structural barriers to just health care have come to the fore? Recall Pellegrino’s emphasis on the attempt to find the right healing action for a patient. This requires a deep openness between doctor and patient to explore the nature of the good for the patient and to choose the appropriate biomedical action in the pursuit of the good. Such openness is always a challenge. But differences in culture, ethnicity, suspicion and the knowledge of previous injustice can make that challenge even more daunting. This requires, in Pellegrino’s words, “paying attention to building trust, being faithful to promises, and removing any basis for a suspicion of discrimination.” Individual action by physicians, however, is not enough to deal with the entrenched structures of inequity in health care: “Collectively, however, health professionals have obligations through their professional associa-

When the health care professional and the patient use institutional Catholic health care, they also accept its public commitment to the Church’s understanding of and witness to the dignity of the human person.

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tions to be advocates for removing injustices in availability, accessibility and quality of services that African American and other groups might experience. If health professionals appreciated the moral power their collective advocacy could exert, they would feel less unable to effect change.”7 Pellegrino’s attention to individual efforts to build trust and collective action by professional organizations resonates with the assertion by Wynia and his colleagues that a key premise for medical professionalism is public profession of values that ensure respect for a moral core so that patients can have trust in the people who provide care for them. A corollary would be that a public

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profession of the values of inclusion, nondiscrimination, personal respect and dialogue on areas of disparity is especially needed in this time when many minority individuals have profound skepticism and distrust about the care they receive. Likewise, the emphasis on dialogue between the profession and members of society on the shared values that should guide medical care implies, for a profession that is underrepresented in minority physicians, that minority communities must have a voice in helping the profession find its moral compass in addressing problems of discrimination and inequity. Bernardin’s description is of a covenant between the physician and patient and its emphasis on actions that promote healing and wholeness, demonstrate real caring and attend to human dignity. It highlights the importance of careful attention to the person who receives care and working to respect the person in need of healing as one made in God’s image and likeness. Inherent and often unintentional bias, a lack of empathy and misunderstanding can prevent the rich covenantal relationship from being formed between physicians and minority patients. As Pellegrino noted, individual actions to listen and build trust are important, but the obligations on the entire profession that are described by Bernardin need attention. These obligations include establishing health care as a basic human right, promoting public health and leadership on protecting human life and dignity in a way that is mindful of limited resources. They take on new urgency when our eyes are opened to wide gaps in mortality, the pernicious effects of social determinants that negatively impact human health and the de facto devaluation of the value of human life and dignity for Black people and other minorities. Institutional Catholic health care, as defined in the Ethical and Religious Directives, is guided by our Catholic faith and its insistence on respect for human dignity and calls for professional patient relationships that are marked by mutual respect and honesty. The defense of human life in Catholic health care appropriately is found in resistance to abortion and euthanasia. But confronted with the facts of health inequity and increased mortal-

ity in minority communities, our faith calls us to continue to assert the dignity of life and work to protect those at the beginning and end of life as well as robust efforts to emphasize the dignity of those whose health and life are imperiled and diminished by structures of exclusion, discrimination and disrespect.

SUGGESTIONS FOR REAL CHANGE

What can the profession of medicine do, concretely, to change how we care for those whose lives are diminished by injustice and racism?

Institutional Catholic health care, as defined in the Ethical and Religious Directives, is guided by our Catholic faith and its insistence on respect for human dignity and calls for professional patient relationships that are marked by mutual respect and honesty.

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More narrowly, what should physicians, management and boards of directors in Catholic health care do to allow the medical profession and other health care professionals to be faithful in their calling in ways that are articulated in the work of Pellegrino, Wynia, Bernardin and the Ethical and Religious Directives? First, the boards of Catholic health care hospitals and systems, in cooperation with management and the chief medical officer, should devise plans that focus on disparate health outcomes and consider how to improve their own institution. This means careful listening to the voices of minority patients, doctors, nurses and others so that their stories are heard. The boards then should devise actions that draw not just on good intentions but efforts to respect, build trust and act faithfully. These actions could include improvements to policies and practices for a more equitable workplace environment, recruitment of minority physicians, nurses and other providers as well as reaching out to the community to hear the experience of minority patients. There is

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a need for deliberate education on the problem of poor outcomes for minority populations, enhancing awareness and reduction of inadvertent bias and the imperative for the profession of medicine to act along with the wider institution. Second, boards can use the structures in place to track outcomes, institute changes and measure success (and the occasional failure) on the path to creating a just and inclusive healing environment. Quality Improvement subcommittees of the larger board are charged with monitoring safety and tracking measures of health care. The approach of these quality committees is often driven by listening to individual stories and then gathering data, constructing pathways for improvement and following results. Patient satisfaction and data on compliance with a variety of health measures are typically the bread and butter of meetings. These subcommittees, with the approval of the larger board, can extend the monitoring of safety and quality to look at satisfaction and outcomes for minority patients and then begin an analysis of where there are disparities, examine the causes and develop methods to improve. Third, the chief medical officers, in conjunction with chief nursing officers, should be empowered to develop educational tools and programs that harness the moral power of the profession to encourage individual practitioners to grow in their ability to treat all patients with deep respect and care, realizing that distrust and difference will be challenges. Just as in promoting safety and quality, the emphasis should not be on blaming or accusing physicians of deliberate bias and poor behavior but a straightforward presentation of the problem and adoption of best practices for improvement. Living through the crises of the past months has not been easy, but the pain and suffering can be the catalyst for growth, change and improvement. Just as our experiences with COVID-19 have changed patterns of practice, created innovations in care and new knowledge, so can the exposure of injustice and racism in health care lead to positive

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change rooted in the best traditions of the medical profession. For Catholic health care, assisting our physicians and other health care professionals to grow in their respect for the lives and dignity of our minority patients is a shared imperative requiring institutional commitment and assistance to our practitioners to enhance and move forward the healing ministry of Jesus Christ. DR. MYLES N. SHEEHAN, SJ, is director of the Edmund D. Pellegrino Center for Clinical Bioethics, a professor of medicine and the David Lauler chair of Catholic health care ethics at Georgetown University Medical Center, Washington, D.C.

NOTES 1. Eliot Freidson, Profession of Medicine: A Study of the Sociology of Applied Knowledge, (Chicago: University of Chicago Press, 1988). 2. Dr. Edmund D. Pellegrino, “Moral Choice, the Good of the Patient, and the Patient’s Good,” in The Philosophy of Medicine Reborn: A Pellegrino Reader, ed. H. Tristram Engelhardt, Jr., and Fabrice Jotterand (Notre Dame: Notre Dame University Press, 2008), 163-186. 3. Edmund D. Pellegrino, “Medical Ethics in an Era of Bioethics: Resetting the Medical Profession’s Compass,” Theoretical Medicine and Bioethics 33, no. 1 (2012): 21-24. 4. Matthew K. Wynia et al., “Medical Professionalism in Society,” New England Journal of Medicine 341, no. 21 (November 18, 1999): 1612-1616. 5. Cardinal Joseph Bernardin, “Renewing the Covenant with Patients and Society,” in Celebrating the Ministry of Healing, (St. Louis: Catholic Health Association of the United States, 1999), 123-132. 6. Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition, (Washington, D.C.: United States Conference of Catholic Bishops, 2018) 13. 7. Lawrence Prograis and Edmund D. Pellegrino, eds., African American Bioethics: Culture, Race, and Identity, (Washington, D.C.: Georgetown University Press, 2007), xvi.

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Human Trafficking and the Path to Whole Healing ALEX GARVEY, PhD Vice President for Mission at Bon Secours St. Francis Health System

uman trafficking strikes at the core of Catholic identity because of the ministry’s deep commitment to promoting and defending human dignity, especially among those most vulnerable. When studies indicated that upwards of 80% of human trafficking victims have seen a health care provider while they were being trafficked, Catholic health care responded.1 Our solutions include raising awareness of the issue in the communities we serve and in training health care providers and staff to understand the signs and identify potential victims of human trafficking. St. Teresa of Calcutta, popularly known as Mother Teresa, understood the deeper and more difficult dimensions of poverty beyond the material and physical. She looked into the eyes of “a person who is shut out, who feels unwanted, unloved, terrified, the person who has been thrown out of society — that spiritual poverty is much harder to overcome.”2 That is why identifying and “rescuing” a victim is only the beginning of a long and arduous journey. Complex trauma, criminal records, alcohol and drug addiction can prevent rescued victims from finding stable housing and employment. Even physical and mental healing may not be enough for victims to fully reintegrate (or, for some, integrate for the first time) into society with long-term stability. The need is for a comprehensive and holistic restoration of human dignity. Collaborating with a myriad of community partners, Bon Secours St. Francis Health System in Greenville, South Carolina, has developed a three-fold process of ministry and care for the victims of human trafficking: the process of rescue, the work of recovery and the ultimate goal of return to society and the world. (Our health system is part of Bon Secours Mercy Health.)

RESCUE

The process of rescue begins with education and training. To increase awareness of this human

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tragedy, St. Francis hosted the first human trafficking symposium in the northwestern region of South Carolina. The symposium was primarily geared toward school counselors, clergy and community leaders. Media coverage of the event spread to five states and led to a collaboration with our local NBC affiliate. This event has grown over five years into a major symposium covered live in both the United States and Europe. The second component of rescue is training staff on the signs and symptoms displayed by trafficking victims. In collaboration with the South Carolina Hospital Association and a local production studio, we created a professional training video to be distributed to all acute care facilities in the state. The goal of this video was to empower staff to see through the combative or hostile nature of patients to recognize when they are victims of human trafficking. The video was filmed in our emergency department with actors and a professionally written script that was edited by survivors of sex trafficking. “Having the survivors’ input in the script was critical and brought a powerfully authentic reality to the video,” said Jessica Weingartner, director of mission at St. Francis. We trained our frontline staff in emergency departments and physician practices and placed posters in English and Spanish in all bathrooms, as often this was the only place a victim was alone.

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Embedded in the poster was a QR code that, when scanned, would add the National Human Trafficking Hotline number to the phone’s contacts under a false name so traffickers, who often search a victim’s phone, would not get suspicious. Lizzy (not her real name) is a survivor. She was only 30 years old when she was rescued from a life of being bought and sold and traded for drugs and cash. When she was deemed young and beautiful by society, drugs and trauma bonds had been the chains which held her to a man who said he loved her but sold her 20 times a night for sex. The hardest part for Lizzy, and other survivors, is not the labels that people apply to them. Rather, it is the way that mainstream society chooses to degrade and devalue them by simply walking past them on the street. Unfortunately, Lizzy only remained in the program for a few weeks before returning to life on the streets. Abstinence-based addiction recovery programs work for some, but for others like Lizzy, it is not enough. The opioid withdrawal and need to feed her addiction were too much for her to handle. Safety and shelter were a first step, but not enough. Rescue needs to be integrated with a full, comprehensive recovery program.

to heal, the promise of meaningful employment and a lifelong community of support. The leaders at Jasmine Road often say their goal is to “love women back to life.” Women who enter the Jasmine Road program come from jails, our emergency department or directly from the street by law enforcement. They now see us as a valued partner. W. Carson Felkel II, MD, the system medical director for behavioral health at St. Francis, is a

The hardest part for Lizzy, and other survivors, is not the labels that people apply to them. Rather, it is the way that mainstream society chooses to degrade and devalue them by simply walking past them on the street.

RECOVERY

Best practice treatment dictates not only removing the victim from the exploitative situation but also providing comprehensive wraparound services for physical and psychological rehabilitation. Jasmine Road, which opened its doors in May 2018, is the only residential program for female survivors of sex trafficking, prostitution and addiction in South Carolina. It was originally funded by St. Francis and two faith-based community ministries in Greenville. Its program evolved from the Thistle Farms housing-first model, developed more than 20 years ago in Nashville, Tennessee. St. Francis took the basic model, and responding to a need, introduced a comprehensive medical health care program. This evolved to host a behavioral program that is unique to Jasmine Road. For the first time, sex trafficking survivors in the state are afforded safe housing, time and space

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child, adolescent and adult psychiatrist who has spoken at the symposium. He joined the opioid taskforce and began working with local agencies to develop programs to support the recovery initiative. Felkel explains that traffickers keep their victims captive by making sure they depend on them for every basic need. A victim who wants to leave has nowhere to go, so often stays in a horrific situation. The trafficker is also the source of the drugs that the victim depends on to numb the pain and control the withdrawal. In this way, the addiction also becomes an essential physical need. “If a victim grew up with abusive parents or experienced childhood sexual assault, she may attach in a chaotic way to her trafficker through trauma bonds. She essentially becomes addicted to bad relationships,” Felkel says. Human beings were created to be in relation with others. We are biologically predetermined to form emotional attachments that support us and help us cope. The residents’ psychological needs are not only met with therapy and psychiatric medicine, but this recovery model provides a sense of love and belonging that the victims might never have experienced. However, it soon became evident that there was a component of providing complete care that we were overlooking.

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Greater than the coercion, physical intimidation or abuse is the devastating terror of opioid withdrawal. Many experts in the field of human trafficking are discouraged by images of women behind bars, but “the actual bars are fentanyl, heroin and prescription opioids,” says Beth Messick, executive director of Jasmine Road. One survivor described the horrors of withdrawing by stating that she could feel pain in every single hair follicle in her body. In response to this need, the St. Francis mission department sought a program that could alleviate this obstacle. Detox and recovery from opioid addiction are key components to stabilizing survivors enough so that women can stay in the program and not return to the streets. This medical intervention into the physical withdrawal trauma is essential to the healing process. Residents who left the safety of the home for treatment ran the risk of encountering predators. Such people lurked at outpatient treatment centers to entice our residents back to the streets by offering opioids. To combat this problem, we applied for and were awarded a $75,000 grant from the Bon Secours Mercy Health Foundation. This funded the first-of-its-kind integration of a Medication for Opioid Use Disorder (MOUD) Suboxone program into the Jasmine Road restoration process. Now the residents benefited from a detox program in the safety of their home. Suboxone binds to and stabilizes the opioid receptors that have been hijacked by trauma and drugs. This provides safety both biologically and psychologically. The process begins to work in about two weeks, but it could take up to a year for the internal dopamine system to get back to normal. Having this program integrated within the residential program provides the safest option for treatment. Without MOUD, detoxing and withdrawing from opioids is just another traumatic experience. Meta-analysis has shown that patients were 1.82 times more likely to stay in treatment and reduced the number of positive drug tests by 14.2%. With MOUD combined with a safe and stable environment, victims have a greater

chance at recovery.3 When Lizzy was rescued from the street into the safety of the Jasmine Road residence, this program was not in place. Even with all the other holistic intervention and support services, the physical addiction was just too powerful.

RETURN

The ultimate goal of any recovery program is to return people healed and whole, stronger and more secure, with both the inner and outer resources needed to feel a sense of belonging again — or perhaps for the first time — into society and the world. This process of return includes three essential points of entry: a fuller sense of self in mind, body and spirit; a fuller sense of community through a return to children, friends and family, almost always lost in a life of being trafficked; and a fuller sense of worth and meaning with a skill and ability to function in society and the world. Moving beyond rescue and recovery requires a new set of structures and processes to ensure a return to a healthy life that is both independent and interdependent. Reaching this goal required further community outreach and collaboration

Detox and recovery from opioid addiction are key components to stabilizing survivors enough so that women can stay in the program and not return to the streets. This medical intervention into the physical withdrawal trauma is essential to the healing process.

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with our partners for fundraising and building these structures and processes. We wanted not just to grow, but to offer more in a second Jasmine Road facility. The hospital owned property with an old mill house that was perfect for a second restoration home. We decided that this was an excellent opportunity to involve the many surrounding faith-based communities in our area. Though other faith communities had shared

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our passion and admired our work, they had not formally collaborated or combined resources with a Catholic health system. To do so, we utilized the expertise of our local foundation and devised a “matching grant” program. In 2019, we designated $100,000 in foundation grant money in a two-for-one matching fund challenge, securing an additional $200,000 from community partners. Thus, we had $300,000 to restore the second home. Unfortunately, renovation was delayed for a year due to COVID. Scheduled for completion in December, the second home triples our capacity to aid trafficking victims. The original home continues to welcome women who come from jails, our emergency department or directly from the street. Many if not all will have serious substance abuse issues. The newly renovated second property will welcome residents who have completed the first year of the program, who no longer require MOUD for opioid addiction recovery and are transitioning into a little more independence. This second property contains two separate buildings. The main house can hold up to 12 women. The property’s second building hosts two independent, two-bedroom studio apartments. These apartments will be for graduates of the two-year program so they can remain connected to the supportive environment while living independently. This will create a space where women can be reunited with children and family they might have lost while being trafficked. In a garage space located beneath the two studio apartments, residents can begin to acquire skills that will help them for success. They make candles, jewelry and tie-dye fabrics as part of their social enterprise, learning both hard and soft job skills. Once acquired, they have an opportunity for the next step. Jasmine Road opened a new venture called Jasmine Kitchen in December of 2019. This is a fully functional kitchen led by community chefs who instruct the residents in the art of preparing and serving food in a professional restaurant in the community. Such mentorship provides the experience required so they can eventually reen-

ter the workplace, and several have. The shame of trafficking has been replaced by a sense of pride in recognizing their own personal strength and dignity. Finally, to avoid regression, the process of return requires ongoing physical, behavioral health and services as well as the need to stay connected to the supportive community of women who share the horrors of human trafficking. They remind each other that although the journey is long and painful, the freedom on the other side is not only possible, but within reach. Messick related the story of running into Lizzy as she was standing outside the gas station two blocks from St. Francis, hopelessly trying to apply mascara. She was reduced to a shivering 90 pounds and was trying to steady her hand in vain.

Coming back to a home that is better equipped medically, psychologically and spiritually will give the Lizzys of this world that human dignity not found on the streets nor in temporary shelters that only stall the inevitable, as people are so often pulled back to the complex cycles.

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“Once our eyes met, she immediately turned her face away, crying ‘Don’t look at me, don’t look at me. I want to come back home, please let me come home.’” Coming back to a home that is better equipped medically, psychologically and spiritually will give the Lizzys of this world that human dignity not found on the streets nor in temporary shelters that only stall the inevitable, as people are so often pulled back to the complex cycles. They need more than “rescue.”

CONCLUSION

As women and men leading the Catholic health care ministry, we need to recognize that the horror of human trafficking is present in the people walking outside our doors and showing up inside our facilities. This is perhaps one of the deepest

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assaults on human dignity. This assault epitomizes a society which Pope Francis describes as promoting “an economy of exclusion and inequality,” that when taken to this extreme treats human beings as “consumer goods to be used and discarded.”4 Rescue, recovery and return can perhaps best be summarized through the rich biblical concept we know as redemption, which is situated in the realities of human limitation and human sin. Slavery, bondage and exile describe not only the Israelites but the women brought into human trafficking. Redemption is setting people free from physical enslavements, psychological discrepancies and spiritual blindness.5 It sets trafficked women free to live not just life but life in abundance. In the Judeo-Christian tradition, redemption is God’s deliverance from slavery, God’s freedom from bondage and God’s restoration of the people, Israel, through the covenant on Sinai, and later with Christ, through the new covenant on Calvary. Our participation in that redemption, then, is the rescue, recovery and return of these women to that original dignity conferred upon them by God before the onslaught of the powers of limitation and sin. Meeting this extraordinary challenge actualizes our belief that “every person is a treasure, every life a sacred gift, every human being a unity of body, mind and spirit.”6

NOTES 1. Laura J. Lederer and Christopher A. Wetzel, “The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities,” Annals of Health Law: The Health Policy and Law Review of Loyola University Chicago School of Law 23, no. 1 (2014): 77. 2. Mother Teresa, “National Prayer Breakfast Address,” transcript of speech delivered at the Washington Hilton Hotel, February 3, 1994, https://www.americanrhetoric. com/speeches/motherteresanationalprayerbreakfast. htm. 3. “Medications to Treat Opioid Use Disorder Research Report,” National Institute on Drug Abuse, (2018): 6, https://www.drugabuse.gov/download/21349/ medications-to-treat-opioid-use-disorder-researchreport.pdf?v=99088f7584dac93ddcfa98648065bfbe. 4. Francis, Evangelii Gaudium, November 24, 2013, https://www.vatican.va/content/francesco/en/apost_ exhortations/documents/papa-francesco_esortazioneap_20131124_evangelii-gaudium.html. 5. Binoj Mathew, “Concept of Redemption in the World Religions: A Comparative Analysis of the Account of Redemption in Semitic Religions and Indian Religions,” IOSR Journal of Humanities and Social Science 21, no. 3 (March 2016): 53. 6. “A Shared Statement of Identity for the Catholic Health Ministry,” Catholic Health Association, https:// www.chausa.org/mission/a-shared-statement-ofidentity.

ALEX GARVEY is vice president for mission at Bon Secours St. Francis Health System in Greenville, South Carolina.

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FORMATION

CULTIVATING OUR INNER ENVIRONMENT: THREE-CENTERED KNOWING

“We can never obtain peace in the outer world until we make peace within ourselves.” — DALAI LAMA

ne of the more unusual outcomes of the pandemic is that a considerable number of people are now familiar, and even engaging, with well-being and self-care from a whole new perspective. Breathing and body scans, mindfulness meditations, loving kindness, heart-opening prayers and reflections are no longer seen solely as the domain of spirituality and religion or as something new age. As Fr. Richard Rohr, OFM, put it in a recent podcast: “These practices have been embraced in a way no one could have foreseen. One could argue that there is a new understanding of contemplative consciousness emerging out of the great pause.”1 During the pandemic, and particularly due to isolation, the meaning of self-care has hugely evolved for individuals and society.2

The Catholic tradition, as well as many other religions, emphasize that the foundation of wellbeing and self-care is cultivating inner peace through our relationship with God. We have arrived at a pivotal moment for our planet’s environment, where this intenDIARMUID tional practice has reached a new ROONEY level of importance. Earth’s survival may depend on the responsibility each one of us takes for maintaining our inner environment.3 Central to cultivating one’s inner environment is the art of bringing attention to what is occurring in any given moment in our bodies, hearts and minds. This message is echoed in the three synoptic Gospels: “What is the greatest commandment?” Jesus of Nazareth responded, “Love the Lord your God with all your heart, with all your soul and with all your mind.” (Matthew 22:36-37) One interpretation of this response is Jesus naming specific centers: heart, mind and soul (which in translation includes the body). For Sr. Ilia Delio, OSF, PhD, Jesus is calling those who would follow him to a new consciousness that involves knowing and loving God with all of these three centers: heart, mind and body.4 This is the

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path that leads us to fullness of life, to wisdom and an abiding inner peace that translates into all our relationships, including with the natural environment. Rev. Cynthia Bourgeault, an Episcopal minister, postulates that inner work and the wisdom this generates can be framed as Three-Centered Knowing — engaging heart, mind and body in a single, integral act of perception. She argues in The Wisdom Way of Knowing: Reclaiming an Ancient Tradition to Awaken the Heart that for Orthodox Christianity and some aspects of Islam, wisdom hinges on the transition to a different mode of perception, classically referred to as “placing the head in the heart.” The heart is understood not as the seat of our personal feelings or emotional lives, but as an expansive space of compassion and love. The Orthodox Greek and Russian traditions refer to the heart as “the organ of spiritual perception,” and the healing of the heart as the engine of our inner (and outer) transformation. Contemporary neuropsychology supports this ancient wisdom. Conditioned feelings and emotional reactions, if not brought into awareness and a healing process, can miss the neurological shift that a person needs in order to move into the vastness of the expanded heart, with deeper capacities of peace, presence and authentic responsiveness.5

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In Three-Centered Knowing, the head is not for most of us. It can be helpful to think of the body the mind as we usually think of it. Rather it’s de- as an interface between the inner subjective self rived from ‘nous’ in Greek, meaning it includes and an objective world beyond the self. Sensitizthe intuitive capacity, our ability to be in touch ing the body to become a fluid medium linking with or aware of the divine. The head can some- self and world, a role it seems purposefully detimes seem like the train of endless and mostly signed for, gives our physical structure an integraworthless thoughts that buzz around continu- tive function far more prominent than its frequent ously, distracting us from our real mind and from dismissal as a machine. presence. Evagrius Ponticus, a Desert Father who lived in the fourth centuSensitizing the body to become ry, wrote at great length on this “logisa fluid medium linking self and moi,” thoughts that lead us away from abiding in peace with “the God of all world, a role it seems purposefully peace.” (Romans 15:33) After multiple interviews with other Desert Mothdesigned for, gives our physical ers and Fathers, he listed the nine passtructure an integrative function far sions or temptations, which later became the Seven Deadly Sins, and the more prominent than its frequent nine virtues that were the antidotes to these passions. Evagrius developed dismissal as a machine. one of the first comprehensive diagnostic and ascetical, or in contemporary language, Martin Schmidt quotes Bourgeault: “I have psycho-spiritual programs, to aid the transforma- learned through years and years of spiritual work tion of what he called “misguided thinking.” This that it’s from a finely developed inner sensing of was done through the practice of self-observation the body that you really get the information you (awareness) and contemplation: to enable, with need to make accurate discernments in your inner grace, a virtuous and peaceful mind leading to a journey. Both the mind and the emotions are easstate of nonattachment and surrender to God. The ily blindsided or manipulated by the personal will. mind, then, is not the endless chitchatting of our But the [body] sensing center never lies. If I am thoughts but an expansive and receptive antenna making a decision and sense inner constriction, I to the signs and signals of the Spirit. know that no matter how much I try to convince Of the three centers, it is the body as a way myself that my preferred option is the correct of knowing that seems the most difficult to un- one, in fact it is not. It has taken years to learn to derstand. In Radical Wholeness: The Embodied discern from sensation.”7 Our relationship with Present and the Ordinary Grace of Being, Philip our body center begins with befriending and recShepherd calls the body or gut “the third brain.” ognizing the perceptivity, guidance and capacity The body has a way of knowing that is different inherent in attending to the subtle presence of from the mind or the heart. Understanding one’s bodily intelligence. Our body prayers, work with internal environment is intimately connected to sensations and sacred movement all deepen our how well you can tap into what he calls “embod- relationship with this center. Cultivating our inied knowing.” Frs. Edwin McMahon, SJ, PhD, and ner environment toward an expansive openness Peter Campbell, SJ, PhD, contend in Rediscover- begins squarely in our capacity for embodiment. ing the Lost Body-Connection Within Christian When we intentionally align these three cenSpirituality that the “mind’s eye cannot easily ters of knowing or intelligence from a place of atpenetrate this inner world of felt meaning” that is tention and self-awareness, we are present. And stored in our cells and tissues.6 to be present is to cultivate inner peace. ThreeSeeing the body as a partner in the quest for Centered Knowing can have a profound impact wisdom and inner peace requires a paradigm shift on waking us to the habitual, often unconscious

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“Whenever your heart space, your mind space and your body space are all present and accounted for at the same time, you can experience pure presence, a moment of deep inner connection with the pure, gratuitous Being of anything and everything. It will often be experienced as a quiet leap of joy in the heart.” —F R. RICHARD ROHR, OFM, from Open Heart, Mind and Body

patterns of the ego that remain the prism — or prison — through which we perceive ourselves, others and the world. The required focus on the immediacy of breath and body awareness can enable a swift but gentle return to presence, allowing for more responsiveness and less reactiveness in our relationships with ourselves, others and the earth. “When a person is poised in all three centers, balanced and alertly there, a shift happens in consciousness, we emanate from a deeper, steadier, and quieter place. We are present, fully occupying the now in which we find ourselves.”8 ‘Peace’ in the Bible can be interpreted as tying together as a whole, or when all essential parts are joined together. Inner peace, then, can be understood as a wholeness of heart, mind and body. Jesus invites us to peace multiple times. This means learning to live and cultivate peace first within ourselves. Then, we can radiate that peace to others, bring-

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ing calmness and wisdom to the reality that every decision and action has an impact on our internal and external environments. By cultivating our inner landscape, we can be lights for healing the world. (Philippians 2:14–15) DIARMUID ROONEY, MSPsych, MTS, DSocAdmin, is senior director, ministry formation, at the Catholic Health Association, St. Louis.

NOTES 1. “Another Name for Every Thing,” Center for Action and Contemplation, podcast March 6, 2021, https://cac.org/ podcast/another-name-for-every-thing. 2. Anne D’Innocenzio and Sophia Rosenbaum, “In Pandemic Era’s Isolation, Meaning of ‘Self-Care’ Evolves,” The Associated Press, November 24, 2020, https://www.voanews.com/covid-19-pandemic/ pandemic-eras-isolation-meaning-self-care-evolves. 3. Sr. Ilia Delio, “Care for Creation,” recorded February 19, 2021, https://www.youtube.com/ watch?v=kmrxfjCl4oE. 4. Sr. Delio, “Care for Creation.” 5. Daniel J. Siegel, Mindsight: The New Science of Personal Transformation, (London: Bantam, 2010). 6. Frs. Edwin M. McMahon and Peter A. Campbell, Rediscovering the Lost Body-Connection Within Christian Spirituality: The Missing Link for Experiencing Yourself in the Body of the Whole Christ is a Changing Relationship to Your Own Body, (Minneapolis: Tasora Books, 2011), 30. 7. Martin Schmidt, “The Essentials of a Curriculum for Self-Understanding: The Body-Mind-Heart Framework in SSS,” Social Conscience and Inner Awakening, https:// martinschmidtinasia.wordpress.com/2018/07/14/theessentials-of-a-curriculum-for-self-understanding-thebody-mind-heart-framework-in-sss/. 8. Rev. Cynthia Bourgeault, The Wisdom Way of Knowing: Reclaiming an Ancient Tradition to Awaken the Heart, (San Francisco: Jossey-Bass, 2003), 36.

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MISSION

MISSION CRITICAL: POST-PANDEMIC WELL-BEING FOR THE VULNERABLE DENNIS GONZALES, PhD and KATHY ARMIJO-ETRE, PhD

he mayor of Santa Fe, New Mexico, recently announced to a group of local partners that he believes we are in the midst of a second pandemic: a behavioral health pandemic tied to the strain of COVID. Within our hospitals and clinics, we experience it daily. We see it emerging in the community, so obvious that it cannot be hidden away in a shelter or housing program that may appear to remove the problem from sight.

As a Catholic health care ministry, we are COVID crisis has taken a toll on the mental health called to recognize and address the extensive and well-being of our population, only adding to fallout and ripple effects of COVID impacting the the already growing number of behavioral health communities we serve. Whole-person care and problems. If hospital utilization in the behavioral health a concern for the general well-being of our colleagues, caregivers, patients and communities is pandemic further tells the story, 48% of the central to our identity and shared mission. If we CHRISTUS St. Vincent inpatient population are to get to a place of post-traumatic growth fol- has a secondary diagnosis of behavioral health, lowing the pandemic, we must first read the signs meaning a medical condition requiring treatof the times and provide people with the care and ment usually related to an addiction to drugs or support they are crying out for today. In Pope alcohol. Over several months at the height of the Francis’ words, it is a time for encounter and ac- pandemic, of all ventilators used inpatient within CHRISTUS St. Vincent, approximately 50% companiment. We see it in the desperate faces of people who were used for patients who attempted suicide have long-standing addictions, and when they contract COVID, suddenly they If we are to get to a place of postunderstand the serious consequences of their behaviors on their health and traumatic growth following the well-being. We see increasing aggrespandemic, we must first read the sion and violence in patients who have addictions, are hospitalized and, as they signs of the times and provide detox, demonstrate behaviors turning people with the care and support them into someone no longer recognizable from who they really are. We see it they are crying out for today. in the despair of adolescents who are depressed and show up in our emergency departments with suicidal ideation. We see it in or abused drugs and alcohol to the point of their the withdrawn faces of our elderly patients who vital organs shutting down. This data included have been quarantined from people they love and patients with COVID and those hospitalized for have sunken into hopelessness. Isolation from non-COVID related conditions. Typically, venfriends and loved ones has led to despair for in- tilator usage for patients with suicide attempts creasing numbers of people, driving emergency and a history of severe drug and alcohol abuse department visits upwards. Some have a general is between 30%–37% at CHRISTUS St. Vincent. Prior to the COVID pandemic, in communities sense of fatigue and low energy because they are just plain worn out from the pandemic. The across the country including Santa Fe, behavioral

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health problems were growing, then were made (July – September 2020). How are the lives of even worse as a result of the pandemic. In the the 22 who received assistance improved? Nine CHRISTUS St. Vincent 2019-2021 Community (41%) of the 22 were successfully housed; eight Health Needs Assessment, behavioral health was (36%) accessed primary care services for the first identified as a priority with drug overdose deaths time; and 13 (59%) were reconnected with family at a rate of 27.2 per 100,000 compared to 19.8 na- or other social supports. Several achieved 30-day tionally. Alcohol-related deaths occurred at a rate sobriety for the first time in many years and nine of 66.8 in Santa Fe County, more than double the (41%) achieved improved functioning in their acnational rate of 32.2. Suicide-related deaths oc- tivities of daily living, meaning they are able to curred at a rate of 26.9, again double the national access food, have transportation and can manage rate of 13.5. Even more alarming is the fact that life on a daily basis. This population illuminates the failures of these are the data from 2017, prior to the pandemic. As we embark upon our next needs assessment, the current service delivery system, one that is we anticipate the worsening conditions to show fragmented and often designed without helping patients to put their own needs first. How can a up in the results.1 In 2011, the CHRISTUS St. Vincent Health Sys- person who is homeless, mentally ill and living tem began the High Utilizer Group Services (HUGS) program. HUGS How can a person who is homeless, is an intensive wraparound and care coordination service for people with mentally ill and living on the streets behavioral health conditions who are possibly show up on time, then wait high utilizers of the emergency department and have high records of an hour or two for an appointment? incarcerations. When the program began, the 25 highest utilizers of the CHRISTUS St. Vincent emergency department on the streets possibly show up on time, then wait had a total of 618 ED visits, 489 inpatient hospi- an hour or two for an appointment? These are the talizations and 628 jail days in 2010. Since the pro- vulnerable who fall between the cracks. Without gram began, hundreds of people have been helped someone to take them by the hand and provide to rebuild their lives. Our skilled HUGS naviga- basic skills, their health and well-being continue tors, who meet people where they are and create a to deteriorate. Although the program capacity is caring relationship, have helped people for whom between 20 to 25 individuals in three-month cojust making it through the day was a battle. Their horts, lives are improved for between 65 and 100 profiles include psychiatric conditions and/or people per year. We have found that the greatest long-standing addictions, homelessness, severe success is achieved within the first three months trauma, limited financial means, disenfranchise- of intensive intervention. While some require inment from family, food insecurity and chronic volvement beyond three months, we maintain onhealth conditions. Through the healing relation- going contact with those who need the support, ship between the patient and the HUGS naviga- assuring them that we will not reject them if they tors, people who had lost hope have been reunited are in need. As we begin to come out of the COVID panwith their families, successfully completed treatment, achieved stable housing, accessed primary demic, we will continue to face huge challenges. care to address chronic health conditions and re- Yet, in Catholic health care, we have a call to care ceived benefits they were due but could not ob- for all of God’s people — body, mind and spirit. We cannot do it alone, however. It takes collabotain. The HUGS program continues to achieve re- ration and partnerships with local and state govsults. From January to June 2020, 22 individuals ernment, nonprofit safety net providers, churches had 246 visits, an average of 11 visits each. With and faith communities, policy makers and philanthe interventions of our navigators, there was a thropy. It takes careful assessment of all public 52.8% reduction for the three months following and private funding and other resources dedi-

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cated to addressing behavioral health. Careful planning and coordination of care is needed so that people who are vulnerable do not get treated like “hot potatoes” passed from one organization to another without getting the help they need. Across Catholic health care, we share the unique responsibility of listening and hearing the voices of vulnerable populations, then passionately advocating on their behalf. We must engage community and system leaders in dialogue to ensure that strategy, decisions, policies and budgets demonstrate a tangible commitment to justice, solidarity and right relationship. It is vital that we remain intricately involved in setting ministry advocacy priorities and collaborating with stakeholders to meet the demonstrated needs of the community. This advocacy encompasses the needs of patients, residents, families and colleagues, as well as the wider community. It is our responsibility to encourage all our coworkers and community leaders to follow the Gospel values demonstrated in the example of Jesus Christ. As such, we all must play a role in helping to restore the health and well-being of our communities, always remembering that we, too, are a part of those communities. DENNIS GONZALES is senior director, mission innovation and integration for the Catholic Health Association, St. Louis. KATHY ARMIJO-ETRE is vice president, mission integration for CHRISTUS St. Vincent Health System in Santa Fe, New Mexico.

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ETHICS

VACCINES: FREEDOM AND THE COMMON GOOD

uch has been written, and publicized, by a sliver of the Catholic community saying that there should be an exemption from the current vaccines because the ones presently available in the United States have a connection with abortions that occurred decades ago. To evaluate this position, it helps to first recognize that freedom, in Catholic theology, is always connected with the common good. Individual freedom is not independent of the community in which we exist. Many may assume that a Catholic and American understanding BRIAN of commonly used terms related KANE to freedom are identical when they are not. As a contrast, let’s look at Rev. Martin Luther King Jr. and Thomas Jefferson. In his “I Have a Dream” speech, King used a central theme, the idea that the founders of the United States had issued a “promissory note,” a debt to all its citizens, that “they have the unalienable rights of life, liberty and the pursuit of happiness.” He believed that “America has given the Negro people a bad check,” and that the promises were unfulfilled. He thought that in calling out the injustice, that all persons of good conscience would “come to realize that their freedom is inextricably bound to our freedom. We cannot walk alone.” That was 58 years ago. He was mistaken — not for his dream or his vision, but about America and its ethics. It is convenient to sanitize King and to manipulate his words to fit a person’s own beliefs about freedom and justice. King was by vocation a Baptist minister. By training at Crozer Theological Seminary and Boston University, he was also a theologian. He was a student of what has been called Boston Personalism, a Christian philosophical tradition associated with the Boston University School of Theology. King’s understanding of freedom is the same as our Catholic sense. To further explain variances in interpretation, we examine the phrase “unalienable rights of life, liberty and the pursuit of happiness” that comes

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from the Declaration of Independence, principally authored by Jefferson. It is fair to say that Jefferson’s understanding of this phrase would be very different than King’s. It is important to put that phrase in context. Jefferson’s full text is that “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” Jefferson’s claim was that these rights are “self-evident.” Having been heavily influenced by Enlightenment thinkers, he thought that reason (self-evident) was superior to faith as a means of knowing truth. In the centuries since Jefferson wrote those words and personally balanced the demands of faith and reason, it is now clear that his gamble on the two ways of knowing truth, faith and reason are no longer in balance. The aspirations of King’s prophecy rested upon his understanding of freedom in a Christian context. American culture is firmly in an extreme Jeffersonian camp. Freedom, and its companion, conscience, need definition to be operative principles. Like King, we use these words but are sometimes confused by disparate meanings that others will use to interpret what we say. To be fair to Jefferson, his understanding of freedom was that license — or an ability to worship as one wishes — should be the governmental stance with regards to religious matters. However, his context needs to be understood. He was against governmental religion, where a government demanded a particular piety. Jefferson was not against worship, per se, just the ability of a government to demand it. Similarly, he respected individual citizens’ right to worship as they wanted. For Jefferson, conscience was to pursue your own liberty. Unfortunately, the trajectory of Jefferson’s compromise has been tilted from freedom “of ” religious belief to freedom “from” religious belief.

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His emphasis on reason has resulted in an abandonment of religious faith as a source of truth, except among the diminishing faithful community. Contrast that with the Christian concept of freedom that King assumes in his “I Have a Dream” speech. It is not unrestrained liberty. Instead, freedom is the use of free will to be moral. We are never free when we choose evil. Conscience is our human faculty to perceive the truth and to act upon it. When we talk about conscience in a Christian context, we refer to our individual faculty to discern right from wrong. Again, this is not unrestrained. Truth itself is objective. We should seek out informed sources, discern and act. Willful ignorance is not an excuse, nor does it mitigate culpability. So, these Jeffersonian and Christian definitions of freedom have resonance for us now as we consider our latest cultural conflict: vaccines. It seems futile to address those in our society who refuse vaccines based upon Jeffersonian principles of liberty at the cost of the community. Instead, I’d like to focus this discussion on the Catholic community, our responsibilities and our freedoms. Therefore, to evaluate this perspective we focus first on the following question: What do we know now? The vaccines available in the U.S. are from Moderna, Pfizer and Johnson & Johnson. Do they have any connection to abortion? The Charlotte Lozier Institute, a research institute that opposes abortion, said Pfizer and Moderna used HEK 293, which it calls an abortion-derived cell line, in their testing of the vaccine. The organization said Johnson & Johnson used another such cell line in the design, production and testing of its vaccine.1 HEK 293 is also used for many processed food products available for sale in the U.S.2 Where is the moral outrage about that?

So, if we look at this reality, is it moral to accept these vaccines given their history? The answer is unequivocally, yes. The abortions that produced these cell lines are incredibly distant from the vaccines that have been developed. The vaccine does not contain the cells of an aborted fetus.3 Given this information, how do we weigh the common good with our desire to be moral? One can still oppose the abortions that produced the vaccine so many years ago because of the remoteness of the act that created the cell line, while also accepting the vaccines that have been created. A corollary instance that might help to clarify is the HeLa cell line that was developed at Johns Hopkins University. This cell line was cultured without consent from a patient diagnosed with cervical cancer, who died shortly thereafter. Her cells were used to study the effects of toxins, drugs, hormones and viruses on the growth of cancer cells without experimenting on humans. These cells have since been used to test the effects of radiation and poisons, to study the human genome, to learn more about how viruses work and played a crucial role in the development of the polio vaccine. One could object to the immorality of the creation of this cell line and still morally accept the fruits of this act.4 To choose not to get vaccinated to take a stand against abortions that occurred several decades ago, rather than choosing vaccination to protect oneself and the many people who could be infected and could die from this virulent virus, seems to be a calculation of Jeffersonian intent. It is certainly not about the common good. Freedom, in a Christian context, means to choose what is good for oneself and for the community. So, here’s the choice: Take an effective vaccine to help thwart COVID-19 and to safeguard each other; or proclaim the immorality

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of abortions from decades ago, and not take any of the vaccines, while allowing the pandemic to spread and people to die. Which is the pro-life choice? BRIAN M. KANE, PhD, is senior director of ethics for the Catholic Health Association, St. Louis.

NOTES 1. David Prentice, “COVID-19 Vaccine Candidates and Abortion-Derived Cell Lines,” Charlotte Lozier Institute, June 2, 2021, https://lozierinstitute.org/update-covid19-vaccine-candidates-and-abortionderived-cell-lines/. It should be noted that Prof. Frank Graham, who established the cell line, says the exact origin of the HEK 293 fetal cells is unclear. Rev. Nicanor Pier Giorgio Austriaco, “Moral Guidance on Using COVID-19 Vaccines Developed with Human Fetal Cell Lines,” May 26, 2020, https://www.thepublicdiscourse. com/2020/05/63752/. 2. Matthew Herper, “Biotech’s Fear Factor,” Forbes, January 27, 2012, https://www. forbes.com/sites/matthewherper/2012/ 01/27/fetal-cells-in-soda-not-quite-the- discomfort-behind-the-controversy. 3. “Vaccine for All. 20 Points for a Fairer and Healthier World,” Pontifical Academy for Life, http://www.academyforlife.va/content/ dam/pav/documenti%20pdf/2020/Covid_ Accademia_IHD_22dicembre/28.12.20_ ENG_VACCINE%20DPIHD%20PAL_ Updated.pdf; “Note on the Morality of Using Some Anti-COVID-19 Vaccines,” La Santa Sede, https://www.vatican.va/roman_ curia/congregations/cfaith/documents/ rc_con_cfaith_doc_20201221_ nota-vaccini-anticovid_en.html. 4. Rebecca Skloot, The Immortal Life of Henrietta Lacks (Sydney, Australia: Picador Australia, 2010); “The Legacy of Henrietta Lacks,” Johns Hopkins Medicine, https:// www.hopkinsmedicine.org/henriettalacks/ immortal-life-of-henrietta-lacks.html.

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H E A LT H E Q U I T Y

ARTIFICIAL INTELLIGENCE IN HEALTH CARE NEEDS SCRUTINY TO ELIMINATE BIAS KATHY CURRAN, JD

“H

ealth care in the United States is marked by extraordinary change,” begins the Preamble to the Ethical and Religious Directives for Catholic Health Care Services. For those working in Catholic health care, we are called to assess and incorporate that change in a way that reflects the full dignity of the human person and improves our ability to preserve health and cure illness. We are on the cusp of a new area of extraordinary change with the increasing use of processes of care utilizing artificial intelligence (AI). New and lightning-fast ways of gathering and using health care data present opportunities for better diagnosis, treatment and patient engagement. But they also raise significant ethical issues, including the risk of further exacerbating and embedding health disparities and inequities in our nation. The term “artificial intelligence” covers a range of technologies that model or simulate human cognitive abilities and include processes such as rule-based expert systems, machine learning, natural language processing and robotics. Using “if-then” rules for clinical decision support and electronic health records is common now, but as the data sets and number of rules increase, the systems can become unwieldy and break down. Machine learning is a more sophisticated form of AI in which computer programs learn from data and algorithms to make inferences and come to conclusions that have not been directed by human input. Deep learning and neural networks use many levels of variables and features to predict outcomes at a level of complexity that can be difficult or impossible for the human user to understand or explain. Another technology, natural language processing, programs computers to decipher and analyze data related to language, such as speech recognition and translation. All of these technologies could be incorporated into physical robots that already can perform simple tasks like delivering supplies in hospitals and more complex functions, such as surgical interventions.1 The power of AI to improve individual health through enhanced quality of care and better outcomes has already been demonstrated and is

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likely to continue to increase. AI can assist with all aspects of the patient care experience. For instance, AI tools are used to analyze patient intake history, risk factors, treatment goals, symptoms and medical condition and make diagnoses, identify possible complications and project treatment outcomes. The AI-generated information assists and supports the doctor in her work, and the patient can access the system to communicate with the physician. One health care system created an algorithm using patient demographic data, medical history and other details from continuous monitoring to detect signs of sepsis in order to warn caregivers, saving an estimated 8,000 lives over five years.2 AI is also being used to give patients more direct control over the management of their health. Earlier and more precise diagnoses can give patients more treatment options. Precision or personalized medicine refers to the ability to tailor treatments to the specific genetic, environmental and other factors that are unique to a patient. With AI-supported precision medicine, that information can be gathered and compared to thousands or millions of other pieces of data about the disease and its management to give a patient more detailed information about his condition and to predict the best options for the patient, instead of

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offering only more generalized protocols. This is care system to identify sicker patients to enroll proving particularly powerful in cancer therapy.3 in a care management program for extra health Patient-facing forms of AI, such as smartwatches services routinely excluded Black patients who and health care apps allow patients to take more were sicker than qualified white patients. The alcontrol over managing their own health care. De- gorithm used health care costs as a proxy for illvices can monitor body processes, provide alerts ness, and health care spending is lower on Black and give access to methods of behavior change patients because of structural inequalities in access to care.6 This is just one example of how that will work for them. AI technology has also been used in the pal- overreliance on flawed algorithms could result in liative care setting to facilitate end-of-life plan- individual patients not getting the care they need. ning and decision making. Researchers at StanA study in the New England Journal of Mediford University developed an algorithm, which is cine identified 13 diagnostics algorithms that inbased on and learns from the medical records of corporated assumptions based on race or ethnicmillions of patients at hospitals associated with ity, which are used by doctors to make clinical Stanford School of Medicine, that can predict decisions about treating patients. One example whether a patient is likely to die within 12 months. discussed was an algorithm used to predict the This information allows palliative care teams to risk of vaginal birth following a previous cesarean reach out to patients and invite them and their families to talk about endAnother concern is whether the of-life goals and preferences before a promise of AI will be available to medical crisis occurs.4 The promise and potential of AI everyone. Precision medicine can to improve health care systems and patient outcomes certainly exists — be very costly. AI could worsen but so do the ethical risks it poses. the injustices that already exist in Biases that subsist in the underlying data or the people who create the our system limiting health care to algorithms can be “baked into” the AI systems and influence the outcertain groups including low-income comes produced. Health inequity communities. is a persistent and lingering legacy of the systemic racism and social prejudices that have far too often been prevail- section (C-section) which assigned higher risk ing characteristics in our nation’s history. CHA scores for women who were Black or Hispanic. and the Catholic health ministry have committed Black women have higher rates of C-sections, to the Confronting Racism by Achieving Health higher mortality and worse outcomes than white Equity initiative to identify and address health women, and algorithms like this can contribute inequity and its root causes in our organizations, to and worsen these disparities. As the authors our communities and our nation’s health system. wrote, “Many of these race-adjusted algorithms It is imperative that as we harness the power of guide decisions in ways that may direct more AI, we are vigilant in ensuring it does not deepen attention or resources to white patients than to and further entrench racial and ethnic biases that members of racial and ethnic minorities.”7 harm the health of the patients we serve. Another concern is whether the promise of AI For example, a system that analyzes the data will be available to everyone. Precision medicine from all clinical trials for a particular condition to can be very costly. AI could worsen the injustices find the best possibility for a given patient would that already exist in our system, limiting health contain inherent racial and gender biases because care to certain groups including low-income comthe subjects for clinical trials are overwhelmingly munities. When the state of Arkansas began using male and white.5 This could lead to inappropri- algorithms to determine how many hours of inate clinical recommendations for some patients. home attendant care would be provided to elderly Additionally, an algorithm used by one health and disabled Medicaid beneficiaries, thousands

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of low-income people lost care they needed to function and survive.8 The starting point for Catholic health care as it engages the challenges and promise of AI should be, as always, the fundamental dignity of the human person and our call to advance Jesus’ mission of compassion and healing. We have committed to the We Are Called initiative, and it is our responsibility to ensure that our own use of AI tools does not create unintentional instances of inappropriate or unjust care for our patients. The We Are Called initiative is the Catholic health ministry’s commitment to concerted and coordinated efforts to achieve equity in our own health systems, facilities and communities and to advocate systemic change in the wider health care sector and our society. For more details, visit https://www.chausa.org/cha-we-are-called/. As Catholic health systems become more directly involved in entities that develop AI and machine-learning products, they should use their influence to ensure the technology is free from discriminatory biases and assumptions. Furthermore, in our advocacy for policies that ensure access to quality health care services for all and end racial and ethnic disparities in health outcomes, we must be ready to call on policymakers to ensure that AI is developed and used equitably as its role in health care grows. AI tools, if developed properly, could play a powerful role in improving health outcomes. But we must ensure that it is not built on data or assumptions that reflect and perpetuate existing biases or structures of systemic racism. KATHY CURRAN is senior director, public policy, for the Catholic Health Association, Washington, D.C.

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NOTES 1. Jessica Morley et al., “The Debate on the Ethics of AI in Health Care: A Reconstruction and Critical Review,” SSRN, November 2019, https://www.academia. edu/40918327/The_Debate_on_the_Ethics_of_AI_in_ Health_Care_a_Reconstruction_and_Critical_Review; Thomas Davenport and Ravi Kalakota, “The Potential for Artificial Intelligence in Health Care,” Future Healthcare Journal 6, no. 2 (June 2019): 94-98, https://www.ncbi. nlm.nih.gov/pmc/articles/PMC6616181/. 2. “5 Ways AI is Improving Care Delivery,” American Hospital Association, https://www.aha.org/aha-centerhealth-innovation-market-scan/2019-12-10-5-waysai-improving-care-delivery. 3. Thomas Davenport and Ravi Kalakota, “The Potential for Artificial Intelligence in Health Care,” Future Healthcare Journal 6, no. 2 (June 2019): 94-98, https://www. ncbi.nlm.nih.gov/pmc/articles/PMC6616181/. 4. Kris Newby, “Compassionate Intelligence: Can Machine Learning Bring More Humanity to Health Care?,” Stanford Medicine, Summer 2018, https:// stanmed.stanford.edu/2018summer/artificial- intelligence-puts-humanity-health-care.html. 5. Morley et al., “Ethics of AI in Health Care.” 6. Ziad Obermeyer et al., “Dissecting Racial Bias in an Algorithm Used to Manage the Health of Populations,” Science 366, no. 6464 (October 25, 2019): 447-453, https://science.sciencemag.org/ content/366/6464/447. 7. Darshali A. Vyas, Leo G. Eisenstein and Davis S. Jones, “Hidden in Plain Sight—Reconsidering the Use of Race Correction in Clinical Algorithms,” New England Journal of Medicine 383, no. 9 (August 27, 2020): 874-882. 8. Jacob Rosenberg, “DHS Rule Change Threatens Disabled Care,” Arkansas Times, October 12, 2017, https:// arktimes.com/news/arkansas-reporter/2017/10/12/ dhs-rule-change-threatens-disabled-care.

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COMMUNITY BENEFIT

10 THINGS TO KNOW ABOUT COMMUNITY HEALTH WORKERS

ommunity health workers can be valuable resources in health care organizations’ efforts to establish trusting community relationships and to address entrenched social determinants of health. They can be part of community health improvement strategies, from prenatal outreach to vaccine acceptance. During the 2021 Catholic Health Assembly, Maria Lemus, founder and executive director of Visión y Compromiso, an organization of promotores and community health workers, described the value and potential of these important workers. Here is a summary of that discussion, along with other information from the literature.

ing or food. The community health worker connects people to these services.

1. Community health workers can help establish trusting community relationships.

4. Community health workers are part of the community.

The American Public Health Association defines a community health worker as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/ intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.”

Community health workers reside in the community. They usually share ethnicity, language, life experiences and socioeconomic status with community members. According to the National Heart, Lung and Blood Institute’s Community Health Worker Health Disparities Initiative, they “can reach community residents where they live, eat, play, work and worship.” The organization calls community health workers “frontline agents of change, helping to reduce health disparities in underserved communities.”

JULIE TROCCHIO

2. Community health workers can impact health and welfare of the community.

Types of impact of community health workers, frequently cited in the literature, include: Outreach to new and existing service recipients. Trust building. Patient and community empowerment once trust is established. A focus on social determinants recognizes that much of what drives health is located in the environment, community or family relationships and that solutions often require resources or services beyond health care, such as transportation, hous-

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3. Community health workers are known by various titles.

Some of the titles used for community health workers include promotores, promotores de salud, community health representatives, community health advisors, lay health advocates, outreach educators, peer health promoters and peer health educators.

5. Community health workers can carry out diverse activities.

Activities carried out by community health workers can include health promotion and health education, assistance in accessing medical and nonmedical services and programs, translation and interpreting services, counseling, mentoring, social support, transportation, case management and risk identification. 6. Community health workers are being tapped for help during COVID.

In 2021, the Health Resources and Services

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Administration (HRSA) of the U.S. Department of Health and Human Services funded nonprofit health and community organizations to mobilize community outreach workers, including community health workers, to educate and assist individuals in accessing and receiving COVID-19 vaccinations. This included activities such as conducting face-to-face outreach and reaching out directly to community members to educate them about the vaccine, assisting individuals in making a vaccine appointment, providing resources to find convenient vaccine locations, assisting individuals with transportation or other needs to get to a vaccination site.1 7. Community health workers provide services in various settings.

The original community health workers and promotores were community members who voluntarily checked in on others, took food to shutins or sick neighbors, gave rides or helped with local information. Today, most of these workers are in community-based organizations or health care organizations such as hospitals and clinics. A recent study found a shift toward health care organization employment. Frequent employers are private and public health and service organizations, community-based organizations, health plans and health systems.2 8. Community health workers are not typical health care organization employees.

Community health workers can be valuable members of the health care team but do not have typical education, credentials and other qualifications of most staff employed by health care organizations. Human resource departments may need to have flexible policies for hiring, training and supervising these workers, permitting them to work to their capacity and integrating them into health care teams. 9. Health care organizations can support community health workers they employ.

Community health care workers can be integrated and supported within health care organizations when they are recognized and respected by others in the organizations, including health care leaders, clinicians and clerical staff. Other staff members should realize that community health workers spend most of their time in the commu-

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nity, not at a desk or even in the health care organization. 10. Health care organizations also can empower community-based health workers.

Health care organizations can support these workers by recognizing their value and treating them as team members. Health care organizations can also assist in funding positions in communitybased organizations or advocating for their funding and use. JULIE TROCCHIO, BSN, MS is senior director of community benefit and continuing care for the Catholic Health Association, Washington, D.C. NOTES 1. “Local Community-Based Workforce to Increase COVID-19 Vaccine Access,” Health Resources & Services Administration, https://www.hrsa.gov/grants/ find-funding/hrsa-21-140. 2. Mary-Beth Malcarney et al., “The Changing Roles of Community Health Workers,” Health Services Research 52, sup. 1 (February 2017): 360-382, https://dx.doi. org/10.1111%2F1475-6773.12657. ADDITIONAL RESOURCES National Association of Community Health Workers, https://nachw.org/. Visión y Compromiso, which supports and advocates for promotores and community health workers, https:// visionycompromiso.org/. “Community Health Worker (CHW) Toolkit,” Centers for Disease Control and Prevention, https://www.cdc.gov/ dhdsp/pubs/toolkits/chw-toolkit.htm. “Community Health Worker Resources,” American Public Health Association, https://www.apha.org/ apha-communities/member-sections/communityhealth-workers/resources. “The Role of Community Health Workers,” National Heart, Lung, and Blood Institute, https://www.nhlbi.nih. gov/health/educational/healthdisp/role-of-communityhealth-workers.htm. “Community Health Worker National Workforce Study,” U.S. Department of Health and Human Services Health Resources and Services Administration (March 2007), https://bhw.hrsa.gov/sites/default/files/bureau-healthworkforce/data-research/community-health-workforce. pdf.

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T H I N K I N G G L O B A L LY

THE GUIDING PRINCIPLES

onesty is the final principle in this series of columns on CHA’s Guiding Principles for Global Health Activities. While these principles are based on research and feedback from collaborations globally and inspired by a desire to improve the impact of our global health activities, honest feedback is not always well received.

There is so much polarization in our world, and trust, which is advanced through honest dialogue, seems harder to find each day. I was recently called the “skunk at the garden party” when providing insights regarding shortcomings of interventions provided globally by U.S. partners. Furthermore, as the COVID-19 pandemic continues, differing political views, media coverage that can increase anxiety or highlight divides, and myths circulating on social media play major roles in eroding trust. In January 2021, the Edelman Trust Barometer, a mechanism that gauges trust and has been around for more than two decades, released the updated Trust Index, which records the average level of trust in nongovernmental organizations (NGOs), business, government and media. A related news release revealed that people don’t know where or who to turn to for reliable information. A majority of respondents believe that government leaders (57%), business leaders (56%) and journalists

BRUCE COMPTON

(59%) are purposely trying to mislead people by saying things they know are false. It also showed that “Trust dropped precipitously in the two largest economies. Respondents deeply distrust the U.S. (40%) and Chinese (30%) governments from the 26 other markets surveyed.”1 Why should we stay abreast of something like a trust index? Because it provides important insights into the things we need to discuss and communicate with our global partners. It points out that keeping open communications and seeking input are paramount when building trust. I invited Laura Berland and Evan Harrel, cofounders of the Center for Compassionate Leadership, to provide insights into trust. Berland is executive director, and Harrel is the chief operating officer. Their insights highlight why being honest and maybe even being called the “skunk at the garden party” is not a terrible thing, especially when building and maintaining trust affects the lives of our brothers and sisters who we are trying to assist.

HONESTY EVAN HARREL AND LAURA BERLAND

he United States and international organizations can have differences in their needs, practices, traditions and definitions of success. These differences can make it hard to speak and share completely openly. What if others criticize us for having different practices or traditions? Will they stay committed to our partnership? Will I hurt their feelings because I have a different view? Speaking up in honest and respectful ways is the role of leaders. If you want others to trust

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you and take risk with you, show your own trust first by being openly honest and vulnerable.

OPEN HONESTY IS HARD

When we allow ourselves to be seen exactly as we are, we reveal our full humanity, including our flaws. Revealing those flaws makes us vulnerable, which no one enjoys. We innately know we are exposed, at risk. Our survival instinct drives us to stay protected, and allowing vulnerability runs

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counter to that survival instinct. Unfortunately, up about their own similar experiences. We all the same walls we put up to protect ourselves noticed the immediate comfort created by this from potential attack also keep out the human honesty, and it allowed others to feel safe and vulconnections that allow for effective collabora- nerable about this issue as well. Each peer started tion and teamwork, and the fear of vulnerability talking about their own situations by first thanking the initial speaker for daring to say the unsaid becomes limiting. Our research at the Center for Compassionate and having the courage to bring this challenge to the surface for the group. Leadership confirms how hard it is for leaders to allow themselves to become CREATE A “YES, GO FIRST” vulnerable. In the midst of CULTURE the COVID-19 pandemic, Start with yourself, and make we asked leaders and their sure you are ready to be fully teams about the leader’s vulnerable when you look at vulnerability. While 54% of yourself in the mirror. The leaders said they were alability to do this arises from lowing themselves to be vulanother of CHA’s Guiding nerable in the midst of the Principles, authenticity. pandemic, only 28% of team Have you moved past many members said that they were of your internal limiting beTrust is earned and learned observing the same thing liefs that keep you from takfrom their leaders. This vuling risks and moving outside Meaningful partnership requires a nerability gap demonstrates your comfort zone? high level of trust and multiple that even leaders who would When you stand fully lines of communication. Both like to show vulnerability in your authenticity and U.S. and international partners have a hard time letting that truth, you are able to hear must recognize that the other intention be seen. ideas that might be differlikely perceives risks in being ent from your own ways of totally honest. Both must listen thinking. You will be much OPEN HONESTY IS A TRAIT for things said and unsaid, which less threatened when your OF A STRONG LEADER partners speak up with a difOne reason leaders resist takes both time and practice. ferent point of view. Receivshowing themselves fully is ing information from such a that they believe that showing human flaws causes them to appear weak. Re- stable, confident position will in turn encourage search shows that just the opposite is true. Lead- your partners to share their full, honest positions. As a compassionate leader, recognize the proers who allow themselves to be seen just as they are often are judged to be stronger leaders. Instead tective instincts among your partners. If they have of appearing weak, this openness causes leaders information that would be useful to you but are to be seen as human and relatable, and makes it hesitant to speak up due to a fear of losing your easier for team members to connect, trust, share valuable support, or of violating your cultural boundaries, then you won’t get the feedback you common goals and work together. When you are brave and speak up first, you need. Explicitly grant permission! Your job is to may find that many other people have been think- make it clear that it is safe for them to express a ing or feeling the same thing as you. In a recent concern or float an alternative, creative idea. You do this through your words and your accohort of compassionate leadership training for global health professionals, an incredibly accom- tions. Model vulnerability, courage and trust. plished and strong leader spoke up about feeling Acknowledge your partners’ unique knowledge isolated and exhausted. All heads were nodding in and let them know that their point of view is very agreement, and several in the peer group opened important to you. Then back up your words with

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U.S. Postal Service

STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRCULATION (Required by 39 U.S.C. 3685)

Let’s imagine a world where we can all speak up in loving, compassionate ways without fear of ridicule or rejection. actions. Honor those who speak up in risky situations, even if their ideas are off the mark. You can celebrate their initiative even if you choose not to move in the direction they suggested. Don’t allow differing opinions to become win/lose scenarios.

IN CLOSING

We all need support. We can never do it all alone. Creating the connection and trust that comes from honesty and vulnerability will be great for more than your organization and your partners. You will benefit greatly as well — no longer will you carry the burden of holding on to secrets. Relax a bit and let your shoulders soften. When we all share from a place of vulnerability and openness, where all ideas are welcome, it calls our best selves forward. Let’s imagine a world where we can all speak up in loving, compassionate ways without fear of ridicule or rejection, where we pour out generous affection without worrying about whether it will be returned. LAURA BERLAND is cofounder and executive director of the Center for Compassionate Leadership in Montauk, New York. EVAN HARREL is cofounder and chief operating officer of the Center for Compassionate Leadership in Montauk, New York. NOTE 1. Edelman Trust Barometer, https://www. edelman.com/trust.

11. 12. 13. 14. 15. 16. 17. 18. 19. 10. 11. 12.

Title of publication: Health Progress Publication number: 0882-1577 Date of filing: October 23, 2021 Issue Frequency: Quarterly No. of issues published annually: 4 Annual subscription price: free to members, $29 for nonmembers and foreign subscriptions Location of known office of publication: 4455 Woodson Rd., St. Louis, MO 63134-3797 Location of headquarters of general business offices of the publisher: 4455 Woodson Rd., St. Louis, MO 63134-3797 Names and complete addresses of publisher, editor, and managing editor: Catholic Health Association, Publisher; Betsy Taylor, Editor; Charlotte Kelley, Managing Editor; 4455 Woodson Rd., St. Louis, MO 63134-3797 Owner: The Catholic Health Association of the United States, 4455 Woodson Rd., St. Louis, MO 63134-3797 Known Bondholders, Mortgagees, and Other Security Holders: None The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes has not changed during the preceding 12 months.

13. Publication name: Health Progress 14. Issue date for circulation data below: Fall 2021 Average No. Copies Each Issue During Preceding 12 Months

15. Extent and nature of circulation: a. Total no. copies (net press run) b. Paid and/or requested circulation (1) Paid/requested outside-county mail subscriptions stated on Form 3541 (2) Paid in-county subscriptions (3) Sales through dealers and carriers, street vendors, counter sales, and other USPS paid distribution (4) Other classes mailed through the USPS c. Total paid and/or requested circulation [sum of 15b (1), (2), (3), and (4)] d. Free distribution by mail (Samples, complimentary, and other free) (1) Outside-county as stated on Form 3541 (2) In-county as stated on Form 3541 (3) Other classes mailed through the USPS (4) Free distribution outside the mail (Carriers or other means) e. Total free distribution (sum of 15d (1), (2), (3), (4) ) f. Total distribution (Sum of 15c and 15e) g. Copies not distributed h. Total (sum of 15f and g) i. Percent paid and/or requested circulation (15c divided by 15f times 100) 16. This statement of ownership will be printed in the Fall 2021 issue of this publication.

Actual No. Copies of Single Issue Published Nearest to Filing Date

14,778

14,600

12,857

12,732

0 0

12,857

12,732

1,626

1,611

0 0

1,626

1,611

14,483 296 14,779 88.77%

14,343 257 14,600 88.77%

I certify that the statements made by me above are correct and complete. Betsy Taylor, Editor

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P R AY E R

SERVICE

Our Blessed Earth: We Are One KARLA KEPPEL, MA, MA MISSION PROJECT COORDINATOR, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

INTRODUCTION Pope Francis uses the term “integral ecology” to refer to the way that, because we are interconnected — with each other, with all other creatures, and with the rest of creation itself — we are tasked with helping to develop a harmonious whole. We know the waters feed the trees, which clean the air, which fills our lungs. Clean water, land and trees are all essential parts of a healthy earth and healthy people. Just as our ecosystem functions or fails as one, so too we thrive or wither as one. Integral ecology is best understood as an invitation: we are each invited to use our gifts and our talents to build up a living ecosystem wherein nothing falls through the cracks, and each part is integrated to the good of the whole. Francis’ description of integral ecology is deeply connected to the common good, which refers to all those social conditions necessary to realize fulfillment and human thriving. Consider how each one of us might work for the benefit of the other, in a world we share together. How might we better ensure the interconnected flourishing of all God’s blessed creation? READING (Psalm 104: 1; 19-20; 24-25) Bless the Lord, my soul! Lord, my God, you are great indeed! You made the moon to mark the seasons, the sun that knows the hour of its setting. You bring darkness and night falls, then all the animals of the forest wander about. How varied are your works, Lord! In wisdom you have made them all; the earth is full of your creatures.

Bless the Lord, my soul! Lord, my God, you are great indeed! INTERCESSIONS As we pray together, the response is, “Bless the Lord, my soul.” We pray for awareness, of ourselves and of the world around us, that we might consciously make space in our hurried lives to notice the dignity of the created world. We pray to the Lord: Response: Bless the Lord, my soul. We pray for courage, that we might become a sincere and ready instrument for peace, beauty and fullness to all people and spaces in need. We pray to the Lord: Response: Bless the Lord, my soul. We pray for the strength to act, that we might be willing to strike out on new paths together to meet the needs of the present. We pray to the Lord: Response: Bless the Lord, my soul. CLOSING PRAYER Creator, you give us life. Help us to honor you as we care for your precious creation. Redeemer, you give us hope. Help us to see new ways of living as we turn from the path of destruction. Holy Spirit, you give us unity. Help us to find strength in the love between us as we seek healing for the Earth. Through Christ, our Lord, we pray: Amen.

There is the sea, great and wide! It teems with countless beings, living things both large and small.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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Community Beneﬁt 101 Virtual in 2021! Community Benefit 101: The Nuts and Bolts of Planning and Reporting Community Benefit VIRTUAL

OCTOBER 12, 13 & 14, 2021 Each day from 2 – 5 p.m. ET

Who should attend: CHA’s CB 101: The Nuts and Bolts of Planning and Reporting Community Benefit, a virtual conference, will provide new community benefit professionals and others who want to learn about community benefit with the foundational knowledge and tools needed to run effective community benefit programs. Attendees will receive a copy of CHA’s A Guide for Planning and Reporting Community Benefit!

What you will learn: Taught by community benefit leaders, the program will cover what counts as community benefit; how to plan, evaluate and report on community benefit programs; accounting principles and a public policy update.

While it is designed for new community benefit professionals, the new virtual format now makes this meeting accessible to a wider audience, including:

v Staff in mission, finance/tax, population health, strategic planning, diversity and inclusion, communications, government relations and compliance who want to learn about the important relationship of their work and community benefit/ community health.

v Veteran community benefit staff who want

a refresher course to update them on current practices, inspire future activities and connect with other nonprofit health care practitioners doing this work.

WE HOPE YOU’LL JOIN US ONLINE! LEARN MORE AT CHAUSA.ORG/COMMUNITYBENEFIT101

NE W S P ON SOR RESOU RCE!

CHA’s new Study Guide for the Second Edition of The Pastoral Role of the Diocesan Bishop in Catholic Health Care Ministry CHA COLLABORATED WITH THE USCCB in providing this resource to foster a clearer understanding of the important relationships and roles of those who are responsible for the Catholic health ministries within the United States.

AVAILABLE NOW!

This new resource is complimentary for CHA members at the CHA Store: chausa.org/store