Health Progress - Summer 2021 by Catholic Health Association

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

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SUMMER 2021

Families and the Pandemic

We are Called TO HEAL. TO UNITE. TO JUSTICE.

“In the diversity of peoples who experience the gift of God, each in accordance with its own culture, the Church expresses her genuine catholicity and shows forth the ‘beauty of her varied face.’” POPE FRANCIS | Evangelii Gaudium (Joy of the Gospel), #116 | 2013

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FEATURES

FAMILIES AND THE PANDEMIC

46 COVID PULLS BACK THE CURTAIN ON SOCIETAL PLIGHT Alexander Garza, MD 51 ADVANCING PATIENT-CENTERED CARE: BRINGING SOCIAL SUPPORT INTO THE FOLD Alisahah Cole, MD and Nicholas Stine, MD 55 A FORMATION ECOLOGY FOR THE DIGITAL AGE Jared H. Bryson, DMin

DEPARTMENTS 2 EDITOR’S NOTE BETSY TAYLOR 60 MISSION COVID, Community and Catholic Identity BRIAN P. SMITH, MS, MA, MDiv 63 HEALTH EQUITY Responsibility Ethics in the Age of Coronavirus AIMEE ALLISON HEIN, PhD 68 AGE FRIENDLY Vatican Calls for New Vision in Caring for the Elderly JULIE TROCCHIO, BSN, MS 72 COMMUNITY BENEFIT Health Anchors Invest to Build Community Wealth, Improve Well-Being BICH HA PHAM, JD and DAVID ZUCKERMAN, MPP Illustrations by Roy Scott

76 ETHICS Techniques to Foster Inter-Religious Dialogue May Assist Clinical Ethicists NATHANIEL BLANTON HIBNER, PhD

4 AS SCHOOLING SHIFTS, WHAT WORKS TO EDUCATE KIDS AND KEEP THEM HEALTHY? David Lewellen

78 THINKING GLOBALLY The Guiding Principles BRUCE COMPTON Authenticity SHAILEY PRASAD, MBBS, MPH

9 THEOLOGICAL REFLECTIONS ON COVID, SCHOOLS AND CHILDREN’S WELL-BEING Mary M. Doyle Roche, PhD 13 IMPROVING MATERNAL AND INFANT OUTCOMES Mary Paul, MA, RHIA and Alli McNeil, MSN, CNM 20 A VIEW THROUGH AN AUTISM LENS Ann E. Guay

19 POPE FRANCIS — FINDING GOD IN DAILY LIFE

26 CHRISTUS HEALTH STRIKES BALANCE TO PROVIDE SAFE, LOVING SUPPORT FOR PATIENTS Debi Pasley, MS, RN

80 PRAYER SERVICE

70 BOOK REVIEW

29 FINDING OUR WAY, TOGETHER Laura Richter, MDiv 35 LETTING EMPATHY GUIDE THE WAY Sr. Linda Yankoski, CSFN, EdD 40 FINANCIAL PROGRAMS FOR OUR WORKERS: THE ULTIMATE RETURN ON INVESTMENT Emily Stevens, MBA, MSW, LCSW-BACS and Coletta C. Barrett, RN, FACHE 44 FEELING BOXED IN, AND MOVING BEYOND IT Ann M. Garrido, DMin

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EDITOR’S NOTE

y sister Cathy just sent me an article from Chicago. It’s about red-winged blackbirds in flight near Lake Michigan barreling into joggers as the birds try to protect their nests. Several years ago, we visited the Lincoln Park Zoo, a place with birds with fancy names like blue-gray tanagers, blue-bellied rollers and the like. We saw a small group of people in the parking lot looking at a tree on the zoo grounds and laughing from time to time. What are they looking at, we wondered? Turns out it was a red-winged blackbird that was swooping down on unsuspecting visitors, pecking them on their heads and flying back to its nest. How funny, I thought, that this bird is upstaging all the animals BETSY and birds that are actually part of TAYLOR the zoo’s collection. We walked the zoo some more with other family members, rounded a bend, walked past a tree, when — PECK! — that bird launched at me from behind, tapped me on my head and flew away again. I wasn’t hurt, and we were in hysterics. As were those spectators still in the parking lot. If there’s one thing I haven’t had much of during this pandemic, it’s those unexpected moments with family. My hope for us as more people get vaccinated against COVID-19 is that we have more of the time we used to take for granted, more of the moments that aren’t occasions, but do become memories. As we worked to put together this issue of Health Progress about families and the pandemic, we thought about all that has changed in the past year and a half. The articles take up a number of ways that our families are linked to our physical, emotional and spiritual health. They detail how to better safeguard and ensure the health of family members, from prenatal and maternal care through old age. They explore challenges that come from caring for family members with mental and physical disabilities. They consider how we can ensure patients have opportunities to be with their loved ones in health care settings whenever possible. Authors look at how much has changed in education and what that may mean for our schools and the social supports they provide. Many arti-

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cles consider health disparities, the gaps that previously existed but have been highlighted by the pandemic. The articles delve into the importance of grounding our work by always thinking about what we can do for our most vulnerable brothers and sisters, both domestically and globally. And the writers talk about our church and health care ministry families, those who think deeply and speak from a place of faith as we work toward systems of care that better serve patients, their loved ones and one another. While I have been at the Catholic Health Association since 2013, this is my inaugural issue as editor of Health Progress. I’ve always been a firm believer that it’s right and good to ask questions and to be OK with not having all the answers. I hope Health Progress readers will continue to see this publication as a forum for sharing ideas, inspiration, challenges, expertise, queries and lessons of faith. I believe every publication is as good as its contributors, so please feel free to contact me, especially if your health care environment is doing work that may spark improvements or change for other individuals, facilities or systems. Throughout the pandemic, we at CHA have spoken to and listened to our membership, trying to gauge what was most needed from us and to match people to new articles, resources or other members who may be of assistance. I’m mindful that people are having very different experiences during this pandemic, and that many of our readers work daily to save the lives of those sick with COVID-19. Thank you. We appreciate you. And my hope is that you have time with your own families. Just keep an eye out for those blackbirds. The editor thanks Mary Ann Steiner, Kathleen Nelson and Karyn Williams for their work on this issue.

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EDITORIAL ADVISORY COMMITTEE 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

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FAMILIES AND THE PANDEMIC

As Schooling Shifts, What Works to Educate Kids And Keep Them Healthy? DAVID LEWELLEN Contributor to Health Progress

hen the COVID-19 pandemic hit more than a year ago, Keri Rodrigues’ kids, like millions of others, did their best to learn through a computer screen. And until this February, that was the best arrangement for them. But as time went on, she could see that her third-grade son was suffering in virtual public school. Every added “day of Zoom in isolation, staring at the same wall,” was worsening his mental health, until “my fear of the virus became less than my fear of isolation,” she said. “My son was dreading his life, at 9 years old.” Rodrigues, a Boston-area mom who is president of the National Parents’ Union, called the local Catholic school where her children had attended two years earlier and arranged for two of her children to start in-person schooling the following week. The two boys were moving toward a much better end to their school year. After her second grader’s first day back, even amidst the masks and plexiglass, he reported when he came home, “I made 10 friends today.” Nothing about going to school in 2021 is normal, but the new arrangement felt closer to it. “He felt that the teacher saw him, and he wasn’t a box on the screen,” Rodrigues said. More than 50 million children are enrolled in K-12 schools in the United States, and over the past year-plus, every one of them has a story to tell about disrupted education. The stories vary wildly. Some children thrived on learning at home, without bullies, distractions or sensory overload. Some children, cut off from friends, food and security, spiraled downward. As a general rule, however, America’s preexisting racial and income disparities have got-

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ten worse. Affluent white children made gains or held their ground; low-income children of color fell further behind. It’s a sad story, but many observers hope that this is a moment when big changes can be made that will benefit the overlooked, especially when “back to normal” is not acceptable. “A lot of parents don’t want to engage with the school system on a good day, let alone in a pandemic,” said Rodrigues, whose organization advocates to improve children’s quality of life and educational experience. Parents who were more comfortable sending their children back early “are used to having their needs met, because they don’t fear the system.” Rodrigues herself bounced between foster homes as a teen and was expelled from school, so she knows that it does not represent a welcoming place for every child. Bullying happens; racism is real. For some children, “school’s not a healthy environment for them. They feel safer at home,” said Kenneth Shelton, an education consultant and speaker in southern California. He told the story a parent relayed to him, saying he’s hearing more instances like it: A Black child saw a class-

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mate wearing an offensive T-shirt on Zoom — hiding the classmate’s image was an easier temporary fix than leaving school or complaining to a principal. Teaching via Zoom presents other opportunities for thinking creatively. Rather than argue with students over turning cameras on or off, Shelton said, “If I were teaching now, I’d encourage students to change their backgrounds as a component of what they’re learning.”

PANDEMIC HIGHLIGHTS EDUCATIONAL DISPARITIES

When Rocketship Public Schools closed in person, “our kids still needed academic support, but we heard about a lot of new needs,” said Juan Mateos, Bay Area director for the system, which operates 20 charter elementary schools in four major markets. Most of their students were lowincome, and housing, child care and food suddenly became more urgent situations for many families. The system scrambled to find electronic devices for students, but Internet access could not be taken for granted, either. Mateos said that Rocketship paid for some families’ Wi-Fi access, and employees had to show grandparents and day-care providers how to log on and join a Zoom session so that the children in their care could attend virtual school. As time went on, the system began offering inperson school, depending on parent feedback and also on local guidelines; there were times when the three California counties where Rocketship has schools each had different rules. For many of Rocketship’s students, “their parents are working the local grocery store, or they’re medical assistants, and they are being recognized for the essential role they do play in society,” Mateos said. But recognition of those essential jobs, for the most part, has not translated into better salaries and benefits. During the mad scramble to shift online, Shelton said, districts were making “stopgap decisions based on the information they had. But once you have more information, an entire year’s worth, what are you choosing going forward? What happened before wasn’t working, and it was a BandAid.” It’s a much bigger issue than just the school system: “We need to hold a mirror to ourselves and society and ask what kind of America we want.” Fair and universal access to high-speed Internet would be a start, he said — and treat-

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“We need to hold a mirror to ourselves and society and ask what kind of America we want.” — JUAN MATEOS

ing big tech companies as public utilities would increase access to education and to many other opportunities. Shelton also thinks it’s significant that across the nation, standardized tests were canceled last spring, even as schools did their best to keep teaching children. If education continues without the standardized tests, “how valuable are they in the first place?” he asked. Power struggles erupted, too — between teachers and administrators, between parents and districts, and between those who insisted that schools must reopen right now (or yesterday) and those who insisted on keeping everyone home until the last arm is vaccinated. Almost every possible variation of hybrid education was tried somewhere or other — split weeks, split days, split classes. In delivering education during a pandemic, “everyone is really frustrated,” said Curtis Jones, a senior scientist in the School of Education at the University of Wisconsin-Milwaukee, “but some people are frustrated about different things than other people.” One family he interviewed was upset about paying $2,000 a month for a private tutor to keep their child from falling behind; another family was parking next to a McDonald’s so their child could have Wi-Fi access. In the fall of 2020, Jones said that with more time to plan, most districts offered much more robust online programming and satisfied more needs, if not all of them. “The average student got a better experience” than in the spring of that year, he said. “But the negative effects were not randomly distributed across the United States.” Just as COVID-19 has hit low-income adults and some communities harder, so have the social and economic impacts. “Every measure you look at, you could say that white middle-class people are doing better than before,” Jones said. “The same could be said for education.” The achievement gap between white students and everyone else seems to be getting even wider, but it draws attention only when white students fall a few months

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FAMILIES AND THE PANDEMIC

behind the standard, not when children of color CAN EDUCATIONAL ADAPTATIONS IMPROVE HEALTH? are two years behind. A first change to adapt to the new circumstances Districts serving more affluent students were we find ourselves in, Rodrigues said, would be a more likely to reopen sooner for in-person learn- summer catch-up session. The custom of starting ing. Large urban districts, Jones said, tend to have a new grade in the fall after three months off is “an stronger teachers’ unions, “and they are under- arbitrary date set by administrators. The needs of standably cautious about going back.” In afflu- children have nothing to do with it.” ent districts, he said, parents have more power Another opportunity to make changes for the and influence because of the leverage of possibly better, Shelton said, is with school start times. withdrawing their children and putting them in Data clearly show, he said, that starting at 8:15 or another district, with a corresponding loss of state 8:30, instead of the pre-8 a.m. times that are relafunding. tively common, reduces traffic accidents, depresMany people say they want to go back to nor- sion, obesity and drug use, and also results in “kids mal, “but Black or brown or Native American stu- who aren’t tired and beaten down at the beginning dents don’t. We need a new normal. We need to re- of the school day.” define what normal is and work toward it. Can we open schools “Everything that we’ve been told is in a way that promotes success more equitably?” Jones asked. impossible is now possible. We’re On average, “white students are learning a lot about how kids learn doing really well. We need to help students who rely on school better and how we can do better...Let’s for more things.” 1 make sure we don’t slide back to the One of those things, the nation has been forced to realfamiliar status quo that didn’t work.” ize, is child care. Teachers will reflexively say that it’s not — KERI RODRIGUES their job to babysit kids, but “Everything that we’ve been told is impossible Rodrigues pointed out that if parents leave their children with someone else, essentially schools is now possible,” Rodrigues pointed out. “We’re do function as a child care system, among their learning a lot about how kids learn better and how other duties. The American economy and work- we can do better. There are a lot of things to love force has come to depend on it, “and it’s the great about this moment. Let’s make sure we don’t slide back to the familiar status quo that didn’t work.” tradeoff.” Cynthia Henderson, a senior practitioner for Social and emotional learning, a growing buzzword in the last decade or two, was also school social work at the National Association pushed to the front burner — parents who might of Social Workers, said, “The kids we sent home not have been aware of it suddenly realized that when we closed schools are not the same kids it was something their children were missing that came back.” Quarantined at home, grieving at home. “We’ve seen a lot of creative and dif- the loss of loved ones or stable routines, relying ferent ways that teachers are trying to teach it,” for help on parents who themselves might not said Justina Schlund, senior director of content understand the academic material or the technoland field learning for the Center for Social and ogy, “imagine the level of frustration.” In lowerEmotional Learning. For instance, the elementary income neighborhoods, sometimes several chilschool custom of “morning meeting,” where stu- dren had to share one device — assuming a parent dents check in with the teacher and each other, didn’t need it. And in rural areas, getting access to easily moved to an online setting, and kids could the internet cannot be taken for granted. “Money talk about how it felt to be in quarantine. “The is the final connection,” Henderson said. Surveys of school social workers found that a energy of students is driving the academic part of the day, because students feel more engaged,” large number had lost contact with “their” kids, and were worried about their food and housing she said.

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situations, and about increased domestic violence. Henderson said she also knew of cases where students were home alone because their parents had to work, and other cases of older children who dropped out of online school to find jobs to help support their families.

WORKING TOWARD EQUITY

“Our Black, brown and indigenous communities have been hit hard by three pandemics,” said Kim Anderson, executive director of the National Education Association — COVID-19, economic disruption and racial reckoning. “Those are all areas of significant trauma to students and educators. This triple crisis has laid bare inequities that have existed for hundreds of years. We have a public education system that was designed inequitably,” first and foremost by relying on property taxes for funding. “That’s the real conversation. Not about who’s to blame, but about how to unravel that system and build an equitable system.” Low-income and minority families have long distrusted the school system, “and for good reason,” said Tomeka Davis, an associate professor of sociology at Georgia State University. “They see the pandemic, and they’re the ones who are

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affected the most.” The past year-plus has “turned the light on to things we weren’t paying attention to. We’ve been talking about inequality in schools for years. Now we have this accident of history, and we see all the problems of inequality. It should make us change the way we do things, but I don’t think anything’s going to change. I really hope I’m wrong.” Anderson asked, “How can we take this moment and use it as a catalyst to build the system we need?” This is an exciting moment. There’s going to be trauma, but once we recover, why not seize the moment to come together? That’s a goal that we’ve never lived up to as a country.” DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.

NOTE 1. Policy Analysis for California Education (PACE), “COVID-19 and the Educational Equity Crisis,” Jan. 25, 2021, https://edpolicyinca.org/newsroom/ covid-19-and-educational-equity-crisis.

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EVERYONE IS CONNECTED

Theological Reflections on COVID, Schools and Children’s Well-Being MARY M. DOYLE ROCHE, PhD Associate Professor of Religious Studies, College of the Holy Cross

he ground seems to be shifting under our feet. As of spring 2021, three vaccines for COVID-19 have been approved for emergency use. Teachers, other Kindergarten-12 education professionals and some students became eligible to receive the vaccines. We have better research data about the transmission of the virus in schools and about serious illness among very young people and adolescents. At the same time, infections continue and variant strains of the virus present new challenges. Public health restrictions are being eased in some states even as we hear cautionary tales from other countries facing renewed lockdowns. Pope Francis, in speaking about the glory of the natural world and human responsibility for our common home, has proclaimed, “Everything is connected.” It is a powerful challenge to the disconnected and compartmentalized way many of us live. The moral imperative to see connections with all of creation and to honor ecological interdependence is also a call to appreciate the stunning complexity of our social lives. Human relationships and social institutions are deeply connected, and personal flourishing is impacted by social determinants. Among the social relationships and structures that deserve much-needed attention are those that sustain and advance the well-being of children.

A PRECARIOUS WEB OF SUPPORT

What has become starkly evident during the pandemic are the many and often hidden roles

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that families and schools play in our common life. Thriving schools and families make many things possible: children who participate in society and dream for their future; parents who can work and build the common good; social relationships among peers and across generations; young people ready to take their place in the world, and elders able to pass on needed insight and values. In many communities, schools also provide a social safety net for children that includes nourishing meals, access to nursing care, counseling and other resources that support learning. While there are broadly adoptable public health measures to prevent the spread of the virus, once we are on the ground in a particular set of circumstances, there is no one-size-fits-all approach. Decisions about closing and opening schools require the skill of a master Jenga player: Some schools and families have the resources to

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adapt to remote learning and the suspension of other kinds of activities. For families and communities whose resources are strapped, pulling schools from the Jenga tower has had serious consequences and ripple effects. Among the many concerning consequences are delays in children’s academic progress and social development, with the most serious consequences for students with learning disabilities. High rates of unemployment, economic instability, and food and housing insecurity jeopardize family and child well-being. There is increased physical and emotional strain on families who are isolated for long periods of time while several members attempt to work and learn in the same space. It is a heavy burden for any family but heavier still for families in close quarters. These ripple effects are exacerbated by racism, sexism and poverty. Women are leaving the workforce at increasing rates to accommodate the education and care of their children. This will have long-term ramifications, especially for women who are Black, indigenous, people of color (BIPOC), low-income women, and womenheaded households. We are reaping the insidious consequences of white supremacy and gender inequality in our schools, neighborhoods, places of employment and health care systems. It’s a dilemma: on the one hand, in the rush to open the economy, BIPOC children and teachers could be placed at increased risk of infection, serious illness and death; on the other, BIPOC students in communities hardest hit with the virus could be denied access to the in-person education and services beneficial to their well-being and the flourishing of their families. We must ask whether the concern for the well-being of BIPOC children and children living in poverty is being exploited by the demand for their parents’ low-wage labor, no matter the risk. Trenchant injustices and inequalities play out in these seemingly impossible choices. Everything and everyone is connected. The pandemic has revealed the ways in which U.S. culture has failed to honor this reality. Enduring patterns of exploitation and injustice have been laid bare. What, then, are the theological resources in the Catholic moral tradition that we might call on when navigating these challenges? There are insights at the intersections of Catholic social teaching, health care ethics and family ethics that can help us keep our footing. Among these are: the dignity of the person as profoundly social and

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interdependent; the need for all people to participate in the common good in spirit of solidarity; the dignity of work and the rights of workers; social and structural relationships that are guided by subsidiarity; and a preferential option for people who are vulnerable and suffering from enduring patterns of injustice.

Everything and everyone is connected. The pandemic has revealed the ways in which U.S. culture has failed to honor this reality. When looked at through the lens of Catholic social teaching, supported with anti-racist and feminist vision, we uncover the root causes of injustice more clearly: a society that undervalues care work, especially the care of children and other vulnerable people; a gender gap in which care work is done primarily by women of color for low wages; care work that is valorized as selfsacrificial in ways that erode social support and undermine the dignity and well-being of women; a culture that prizes competition over cooperation in the goals of education, encouraging parents to seek and gain advantage over other people’s children; underfunded schools in BIPOC neighborhoods; a corporatized, private industry model of education that cannot secure equity; and many families under considerable strain financially and emotionally relying on open schools as a key to survival and socioeconomic mobility.

FAMILIES, SCHOOLS AND INTERGENERATIONAL SOLIDARITY

Early in the pandemic, the evening news featured stories of teachers going the extra mile for their students, waving banners of support from parading cars. Many people were brought to tears by this witness to mercy and compassion for children. But as the pandemic wore on and children remained at home, pressure mounted to reopen schools. Teachers rightly demanded adequate personal protective equipment, social distancing measures, access to regular testing and vaccination before returning to classrooms. Parents weighed in on both sides: some demanding that schools return to classroom learning for the bene-

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fit of their children and families, others reasonably cised at the expense of the well-being of other fearful about the potential risks to public health children. Parents are the first and primary educators of and the racial disparities in health outcomes. The first task in Catholic social teaching is to their children. This insight is crucial if we underask, “What is going on?” This phase of moral delib- stand that its corollary is the additional need for eration is done without judgment and with mercy. social supports for families. The thrust of this It requires attentive listening and looking in a situ- teaching, however, has been in protecting paration marked by suffering. We share our particular ents from interference, particularly by governexperiences of a situation and open ourselves to ment, in deciding what education best serves the experiences of others. We challenge ourselves their children, especially as it relates to sex eduto be present to those whose experiences are dif- cation. The emphasis has not been on what parferent from ours. We look at the data to explore ents can demand from the government in terms patterns of experience, advantage and injustice. of support for educational equity. This has been Shared narratives begin to emerge from anecdotal a missed opportunity. Caring for and educating children is essential work that begins in the family, and deeply personal experiences. We analyze the data to map out the most imme- extends beyond the family and should be honored diate and urgent needs, but also to uncover the with just wages and working conditions. Children root causes of injustice and disparity. We iden- themselves participate in the common good and tify gender inequality and patriarchy, racism and deserve safe and secure places to learn and play at white supremacy. We admit the enduring low home and in the community. The church’s teaching on family life is grounded status of children in spite of the romanticized rhetoric about how we love and cherish them. We in a call to intergenerational solidarity. It serves look for connections among the roots that anchor neither children, nor teachers, nor elders in the and fuel what is visible. We ready ourselves for community for these groups to be in competition uprooting, pulling up entrenched perspectives to with one another for resources and protection. make room for new growth nourished by the good For many parents and grandparents, participation in the life of children and school is a major form of news of the gospel. The impacts of COVID-19 and its aftermath on civic participation. Relationships between young children ask us to reflect in a focused way on the people and elders are mutually beneficial; no one church’s teaching about family life and education. The pandemic Evidence from the pandemic suggests has exposed many of the chalseveral areas that need development lenges of raising and educating young children, caring for elders within the church’s teachings on and the need for wide and multichildren, family and education. valent layers of support in order to accomplish these tasks. The church’s theological, spiritual and pastoral tradi- is merely a burden, no matter how vulnerable. It is vital that solidarity extends across generations tions listed below can play a crucial role. The family is the first cell of civil society, and and beyond school district lines. Evidence from the pandemic suggests several the church itself is a family of families. It is a building block for the rest of the social order. Families areas that need development within the church’s are not merely private havens from the wider teachings on children, family and education. First, world. It is where children come to learn how to we must challenge the highly gendered view of care for and about others. Family responsibility to marriage, parenting and other roles in society the common good encourages us to resist a com- as well as the low status of care work involving petitive approach to well-being that continues young children and elders. We must balance the to disadvantage children living in conditions of inevitable sacrifices this work requires with a material poverty and children in communities of commitment to justice for all who make those saccolor. As a parent, this can be extremely difficult rifices, including teachers. The gendered nature to resist, but the responsibility we carry for the of this work has rendered it less valued, and the well-being of our own children cannot be exer- self-sacrifice of teachers is too often praised in

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We need more attention to the many roles that schools play in the lives of children as places of education, formation for participation in civic life and social safety nets. ways that erode commitment to just wages, safe teaching conditions, security and advancement. Second, the church should offer more robust support for public education. We need more attention to the many roles that schools play in the lives of children as places of education, formation for participation in civic life and social safety nets. Public schools are required to provide education for all children in ways that Catholic schools are not. We need stronger advocacy for teachers. We see also that schools are a linchpin of the overall economy. The ability for adults to work to earn their livelihood and to live a vocation outside the home relies on functioning and flourishing schools.

PARADES, PROTESTS AND RECOMMITMENT TO CHILD HEALTH

Child health and well-being are impacted by many social factors. The common good tradition according to Catholic social teaching strives to create conditions that allow people and communities to prosper in so many ways, including good health. The pandemic in the U.S has disrupted this vital network on a massive scale. Access to adequate and equitable primary education is a key social determinant for the long-term health and well-being of young people. We need parades to honor this essential work and protests to demand justice for all children, parents and teachers. The COVID-19 pandemic is not likely to be an isolated incident in a world where everyone and everything is connected. If those connections are marked by intergenerational solidarity for the common good that cross every kind of border and boundary, we can meet future challenges, mitigate their most devastating effects, and ensure the health and well-being of future generations. MARY ROCHE is an associate professor - theology at Holy Cross and the author of Schools of Solidarity: Families and Catholic Social Teaching.

QUESTIONS FOR DISCUSSION Author Mary Roche, PhD, describes how the pandemic laid bare enduring patterns of injustice, how society undervalues care providers and the importance of thriving families and schools to overall health. 1. Is there an aspect of Catholic social teaching she highlights in this article that has particular resonance for you as you think back on recent months? How did it help to shape your views on the pandemic or on a needed societal reform? 2. The pandemic brought sudden shifts in how we experience work, home and educational life. Did these changes lead you to new thinking on how families, workplaces and schools affect health? As you reflect on these changes, do you see ways that we can build more responsive societal systems for greater flexibility in work-life balance? What does that look like for your colleagues who care for young children, elderly parents or other family members? 3. Had you previously viewed schools as so integral to health? In what ways does your organization currently partner with schools in the community? Do you think a greater understanding that schools provide some safety net services for children and their families might lead to new relationships between health care systems and schools? What might these look like? 4. Sometimes parents want what’s best for their children, and don’t always extend that thought out to wanting what’s best for all children. Roche makes the point that by downplaying competition, we can seek the well-being of all children. Do you see new ways to be more supportive of families and children? How so?

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FAMILIES AND THE PANDEMIC

Improving Maternal And Infant Outcomes Listening, Responding and Healing Social Systems

MARY PAUL, MA, RHIA and ALLI McNEIL, MSN, CNM Ascension

aternal and infant health outcomes are at a crisis level in the United States. Despite advances in medicine and the presence of vast health care resources, women in the U.S. are more likely to die from complications from pregnancy or childbirth than women in similarly developed nations.1 Maternal and infant mortality rates reflect many societal factors that highlight health disparities. The factors that drive these disparities are complex and may lead to, or even cause, poverty. Barriers to health and health care include access to food, housing and education; mental health issues; transportation; and access to culturally relevant health services. Wide racial and ethnic disparities in maternal mortality rates have been reported for decades. While data reporting methods have varied, the results consistently reveal that maternal mortality rates for Black, non-Hispanic women are three to four times greater than for white women in the U.S.2 In addition, the Maternal Health Task Force at the Harvard T.H. Chan School of Public Health further reports that while women of color have poorer access to high quality reproductive health services than women who are white, they are also discriminated against in the health care system and experience higher rates of disrespect and abuse. There is evidence that the stress associated with these experiences of racial discrimination can increase the risk of negative perinatal outcomes for Black women. These socioeconomic and racial disparities can lead to a general cycle of poverty, which leads to higher maternal mortality rates.3

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Persistent inequities and disparities in maternal and infant health raise important questions about how society and its systems shape the destiny of persons in poverty by shaping, in part, their personal identity. What becomes real to a person is complex and is often partly defined by what we think others think of us. In other words, are broken social systems contributing to how some women in poverty might subconsciously fulfill an expectation of society that they will fail in their responsibilities? Is it possible to improve maternal and infant health by enabling a positive personal identity through a better response to the social needs related to the perinatal experience?

GETTING STARTED: MATERNAL HEALTH SOCIAL SYSTEMS INITIATIVE

In 2019, Ascension responded to this opportunity to identify broken social systems and developed solutions as a pathway to improved maternal health outcomes by launching the Maternal Health Social Systems Initiative. Early and adequate prenatal care promotes healthy pregnancies through screening and management of a woman’s risk factors and health conditions while encouraging healthy behaviors during pregnancy. A number of studies have demonstrated an association between fewer prenatal visits and poorer

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FAMILIES AND THE PANDEMIC

pregnancy outcomes, such as low birth weight, preterm birth and infant mortality.4 By reviewing data on prenatal appointment attendance, Ascension identified ministry markets within our larger health system where this initiative would have the greatest impact. For years leading up to 2019, the no-show rate for prenatal appointments in Milwaukee, Wisconsin, was more than 20%. Using that data, we approached the social barriers to good perinatal care by utilizing the newly developed Ascension Social Response Framework, a simple, unconventional care model that prioritizes listening to and organizing learnings from individuals in the communities we serve. By doing so, we have developed data-driven solutions that address systemic social barriers. While the solutions are specific to the maternal population, the framework applies to any problem that requires deeper understanding.

LISTENING AND ENGAGEMENT: BUILDING TRUSTING RELATIONSHIPS

eled against this very vulnerable population. The health care workers must be able to recognize a patient’s struggles and vulnerability, and then respond without judgment. Further, the relationship must promote free agency and decision-making, rather than create new dependencies. Lastly, the maternal health navigator and community health worker must have a working knowledge of the community and its resources, in addition to the ability to navigate the health care systems and providers. These capabilities and attitudes allow for a trust-building relationship that is centered in mutual respect. Once this relationship is formed, appointment attendance and engagement in the care process improve. Within the first six months of the Ascension initiative, there were early signs of progress and a steady decline in the number of missed appointments in Wisconsin, which continues to be sustained at an all-time low. Additionally, there is a continued increase in infants born full term (3.9%) and at a healthy birth weight (3.1%) among the women served compared with those without the social support of the initiative during the same time frame. The team also has responded to the needs of more than 700 women referred from

Deep listening reveals complex underlying issues of not only vulnerable persons, but also the complexity of accessing existing solutions. To assist women through this complex arena, maternal health navigation was identified as an essential element that links the The role of the maternal health woman, her community and the clininavigator is critical in identifying cal setting. The role of the maternal health navigator is critical in idenand connecting patients to existing tifying and connecting patients to existing Ascension and communityAscension and community-based based resources. Walking alongside resources. the woman, guiding and assisting her through barriers to prenatal care, allows for a “warm handoff” to clinical services, multiple sources including OB and primary care while building trusting relationships with our clinics, the emergency department or community partners. It is well known that responding to these patients, community and clinical providers. Early on, it became evident that communica- variables contributes to the long-term health of tion was a leading barrier to prenatal care. Phone the mother, child and community. These results numbers and addresses were not always current, led to the expansion of the initiative across several voicemail boxes were often full and many cell ministry markets, including Florida and Michiphones were out of service. The addition of a gan, with a goal to reach all markets within the community health worker allowed the maternal next 12 months. health team to find ways to communicate with patients outside of the traditional methods. This THE IMPACT OF COVID-19 one-on-one engagement with women became Maternal health has been in crisis since long the foundation for building a trusting relation- before the pandemic. The social systems that ship, but the success lies in the selection of the women and families routinely access and rely on right maternal health navigator and community are increasingly scarce or are unable to meet the health worker. Society’s prejudices are often lev- high community demand exacerbated by COVID-

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19. Rideshare and public transportation services may be more beneficial when women also are are being reduced and even eliminated, access provided with nutritional support. That pairing of nutritional support and educato nutritional support has decreased, childcare centers have closed, and policies limit who may tion led Ascension to develop diagnosis-specific accompany patients to their visits. The unin- food boxes that are initiated by prescription and tended consequences of these changes can leave then dispensed through the pharmacy. The boxes pregnant women even further separated from the prenatal care they Maternal health has been in crisis need. Ascension has implemented the following solutions to respond to since long before the pandemic. identified barriers heightened by the The social systems that women and pandemic.

FOOD ACCESS: BRIDGING THE GAP

families routinely access and rely on are increasingly scarce or are unable to meet the high community demand exacerbated by COVID-19.

Optimal maternal and fetal outcomes are dependent upon the intake of sufficient nutrients to meet maternal and fetal requirements.5 Reducing household food insecurity is an intervention that can contribute directly to improved maternal nutritional status, thus improving these outcomes. High community demand during the pandemic has led to an increase in food insecurity among pregnant and postpartum patient populations. The maternal population is not only at increased risk for complications due to nutritional deficiencies, but many of these women also are vulnerable when it comes to food resources in general, compounding vulnerability with nutritional deficiencies. To address this problem, we developed a systematic and scalable food access program to bridge the timing gap between when the need is identified and when the woman is able to access community-based food programs. At the time of service, women and families in need may receive a bag of nutritionally sound food items along with assistance in accessing appropriate and available community resources to continue that support.

FOOD ACCESS: NUTRITIONAL EDUCATION AND SUPPORT

Pregnant women are at increased risk for iron deficiency anemia, gestational diabetes and hypertensive disorders. When these conditions are poorly managed, there is an increased risk to maternal health and pregnancy outcomes. Conversely, evidence suggests that nutrition education and counseling may support optimal gestational weight gain, reduce the risk of anemia in late pregnancy, increase birth weight and lower the risk of preterm delivery. Dietary counseling and education

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contain not only the food items, but also recipes and educational materials. The food boxes provide concrete examples of good nutritional choices for patients who can then make better purchasing decisions at grocery stores. The boxes may also allow patients to try unfamiliar foods that they might have been hesitant to try due to limited finances. Patients may discover that they and their families like these choices and choose them again — resulting in healthier patterns of nutrition.

CHILDREN’S WAITING AREA

In March of 2020, efforts to control the spread of COVID-19 were being implemented across the United States. New processes, including calling ahead to screen mothers for symptoms, encouraging them to attend appointments alone, and providing a telehealth option, were implemented but have proven to be insufficient. The continuation of virtual learning for the majority of school systems and subsequent lack of childcare options within communities made attending appointments even more difficult for pregnant women. While these efforts to control the spread of COVID-19 are important, health care practitioners were often unaware of the impact of certain policy changes on access to health services, including routine prenatal care. Keeping in mind the importance of offering solutions that are easily accessible to the patients, Ascension created a children’s waiting room to

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promote access for patients seeking essential prenatal care. In partnership with nursing programs, an area adjacent to the clinical setting was designated where nursing students could supervise children while their mother attends her appointment, which may include ultrasound, iron infusions or routine prenatal visits.

MOBILE COMMUNITY OUTREACH

can be attributed to complications related to prematurity (delivery before 37 weeks of pregnancy). The City of Milwaukee has a premature birth rate of 12.9%, well above that for the county (12.0%) and the state (9.9%).7 Milwaukee is also one of the most segregated cities in the U.S., with some of the greatest disparities for health and social outcomes, which contribute to the daily stressors experienced by pregnant African American women.8 Jequeta Hamm, a lifelong resident of Milwaukee, knows very well the everyday stressors and barriers expecting mothers face. In 2010, Hamm gave birth to a healthy baby girl; however, despite her persistent complaints of feeling unwell and pleading with providers to assess her condition prior to discharge, she was sent home. Three days after discharge, she awoke, gasping for air, unable to breathe. Hamm found her discharge instructions and called the clinic for advice. She was instructed to go to the emergency department and was admitted to the hospital with high blood pressure, pulmonary edema and congestive heart failure. “I feared for my life. Here I am in the hospital, away from my new baby, not knowing if I was going to live,” she said. After almost a month-

Appointment attendance for socially and medically high-risk pregnant women is essential. It is also critical that we continue to manage prenatal needs while using proper infection control precautions. New infection control processes have been implemented to protect providers, patients and the public. While these new processes are important, they can increase patient fear and concern that the hospital and clinic environments are unsafe. Additionally, the availability of proper personal protective equipment is often limited, which can leave the patient and family members feeling more vulnerable. These added stressors to women who are already at-risk may contribute to poor health outcomes. As an alternative to attending visits in the clinic or hospital setting where patients may be fearful of exposure to COVIDAppointment attendance for socially 19, Ascension created a prenatal outreach program. A care team, includand medically high-risk pregnant ing a certified nurse midwife, is readwomen is essential. It is also critical ily available to be deployed to support the community health worker along that we continue to manage prenatal with all the supplies needed to ensure the safety of all involved. Patients are needs while using proper infection given thermometers and masks and control precautions. educated on personal safety as well as the importance of routine prenatal care. Prior to the home visit, the community long hospitalization and cardiac rehabilitation, health worker also calls to assess the need for Hamm was sent home and told by her provider supplies such as diapers, wipes, food and bottled “you probably shouldn’t have any more babies and water, which can be provided at the visit. After you need to live a stress-free life.” visiting the patients in the community, they are At that time, Hamm knew she wanted to have more inclined and better equipped to attend their more children but was very afraid of the health visits in the clinic setting. consequences. In 2018, she decided to undergo an extensive cardiac work-up to see if pregnancy would be safe. The examination revealed it could COMMUNITY OUTREACH: A SURVIVOR’S STORY In 2015, Wisconsin reported its highest Infant be safe, but she would have to be closely moniMortality Rate disparity between Black (14.5) and tored. On April 27, 2020, Hamm gave birth to white (4.7) infants, with Black infants three times Rayasia Cousins, who was born healthy and withmore likely than white infants to die before their out complication. Unfortunately, this was during first birthday.6 The majority of Wisconsin infant the peak of the COVID-19 surge in her community. deaths occur in the Milwaukee central city and Within 36 hours of delivery, Hamm and Rayasia

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were discharged, where they could recover in the safety of their own home. Several days later, Hamm began to develop headaches and called her provider for advice. She returned to the clinic, was told everything was OK and went home. Things were not OK, and the next day symptoms worsened. Due to a lack of transportation and childcare, she was not able to go to the hospital for evaluation. Fortunately, the Ascension Wisconsin maternal health team had just launched the mobile outreach program. The community health worker contacted Hamm, went to her home with a certified nurse midwife and performed an evaluation. Her blood pressure was extremely high, and she was admitted directly to the hospital where she spent four additional days for treatment. “I feel more hospitals should have programs like this. They went above and beyond to take care of me. Where were y’all when I had my last baby? I feel like they sent me home to die. I kept telling them something was wrong with me, but they didn’t listen,” said Hamm. She states the key to the program is the relationship she has created with the community health worker. Instead of waiting 2 to 3 hours for a nurse to call back from the doctor’s office, she can quickly text or call the community health worker with questions or concerns, always knows who she is going to talk to, and trusts the information and advice she is given.

CONCLUSION

These learnings and experiences are examples of the socioeconomic conditions and racial biases that contribute to a general cycle of poverty which leads to higher maternal mortality rates. As the work continues to grow in ministry markets across Ascension, patterns are beginning to emerge that allow us to identify focused opportunities to bring a system-wide approach to advancing health equity. The application of the Social Response Framework continues to illuminate opportunities for growth and support of our most vulnerable populations. We are called to respond to the needs of all, but those with the greatest needs require the greatest response. We strengthen the whole of the community by responding to the needs of people who are most vulnerable.9 The time is now to respond to the maternal health crisis in a way that reflects our deep listening and love for all.

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MARY PAUL is the vice president of solidarity and social accountability for Ascension. She is also currently a master’s student in Catholic Clinical Ethics at Georgetown University and The Catholic University of America. ALLI McNEIL is director of solidarity for Ascension.

NOTES 1. Munira Z. Gunja et al., “What Is the Status of Women’s Health and Health Care in the U.S. Compared to Ten Other Countries?,” The Commonwealth Fund, 2018, https://doi.org/10.26099/wy8a-7w13. 2. “Morbidity and Mortality Weekly Report” 47, no. 34, Centers for Disease Control and Prevention, (September 1998): 705-707, and “Pregnancy Mortality Surveillance System,” Centers for Disease Control and Prevention, 2020, https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system. htm. 3. “Maternal Health in the United States,” Maternal Health Task Force at the Harvard T.H. Chan School,” n.d., https://www.mhtf.org/topics/ maternal-health-in-the-united-states. 4. Elizabeth A. Howell, “Reducing Disparities in Severe Maternal Morbidity and Mortality,” Clinical Obstetrics and Gynecology 61, no. 2 (June 2018): 387-99, doi: 10.1097/GRF.0000000000000349. 5. José Villar et al., “Nutritional Interventions during Pregnancy for the Prevention or Treatment of Maternal Morbidity and Preterm Delivery: An Overview of Randomized Controlled Trials,” Journal of Nutrition 133, no. 5 (May 2003): 1606-25S, 10.1093/jn/133.5.1606S. 6. Lucy Mkandawire-Valhmu et al., “Enhancing Healthier Birth Outcomes by Creating Supportive Spaces for Pregnant African American Women Living in Milwaukee,” Journal of Maternal and Child Health 22 (December 2018): 1797-1804. 10.1007/s10995-018-2580-4. 7. “WISH Query System,” Wisconsin Department of Health Services, 2019, https://www.dhs.wisconsin.gov/ wish/lbw/form.htm. 8. Lucy Mkandawire-Valhmu et al., “Enhancing Healthier Birth Outcomes.” 9. Economic Justice for All: Catholic Social Teaching and the U.S. Economy, Washington, D.C.: United States Conference of Catholic Bishops, 1986, https://www.usccb. org/upload/economic_justice_for_all.pdf.

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Remo Casilli/Sintesi/Alamy Stock

Finding God in Daily Life Do you have a feeling of failure or inadequacy, the fear that you will never emerge from the dark tunnel of trial? God says to you, “Have courage, I am with you.” He does this not in words, but by making himself a child with you and for you. In this way, he reminds you that the starting point of all rebirth is the recognition that we are children of God. — Pope Francis homily, Solemnity of the Nativity of the Lord, Vatican Basilica, Dec. 24, 2020

FAMILIES AND THE PANDEMIC

PARENTING DURING A PANDEMIC

A View Through An Autism Lens ANN E. GUAY Pro Bono Attorney with Massachusetts Advocates for Children

n March 15, 2020, Gov. Charlie Baker ordered all public and private schools in Massachusetts to close for three weeks due to COVID-19. Parents of school-age children had to learn to juggle careers with remote learning, Zoom calls and no child care. College students were back home in their old rooms and not happy about it. Facebook pages were flooded with posts from parents struggling to get through the day. Parents were running on fumes, worried about the long-term impact of COVID-19 on their children’s education and mental health. Sports seasons were cancelled, and graduations postponed. Three weeks turned into 13 months, and while many schools have reopened in some capacity, life is certainly not back to normal. Like many parents, we worried about the impact of the pandemic on our children. Our youngest son’s senior year of college ended abruptly, and we questioned whether our daughter should start business school. But the biggest challenge we faced was helping our 26-year-old son, Brian, who has autism, epilepsy and an intellectual disability, cope with how much his life changed. For families like ours, this pandemic was especially difficult for reasons many may not understand. According to the Centers for Disease Control and Prevention, autism spectrum disorder is a developmental disability that can cause significant social, communication and behavioral challenges. While some individuals with autism have normal intelligence and can communicate, others have challenging behaviors and can be nonverbal. About 1 in 54 children has an autism spectrum disorder, which is four times more prevalent among boys than girls. What these statistics do not reveal

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is that these children grow up and become adults. Brian keeps active and thrives on routine. A 3-by-4-foot calendar hangs on his bedroom wall, and he writes his work schedule every Sunday night in erasable marker. His room is next to ours, and we can hear every deliberate stroke of his marker as he writes. It is worth noting that we are not allowed to ask him about his schedule. We are told to read the calendar. Brian works at a HomeGoods four mornings a week and at two local farms a few afternoons and on Saturdays. He loves to draw and sells his art to family and friends. He redeems cans for the deposits and saves everything that he earns so that he can one day buy a farm like his ancestors. Brian likes to go to the movies, eat out, row and works out at a local gym with aides a few afternoons a week. He has benefitted from excellent schools and therapies and has made great progress but will never live independently. Brian is also lonely, wishes he had a girlfriend and does not believe

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he has a disability. We made peace with Brian’s tor validated what he was feeling. These sessions diagnosis years ago and believed we were ready were so helpful, and I hope they continue. A particularly painful time for me was when for what life would bring. Nothing prepared us for I had to complete a COVID-19 disability form in COVID-19. Brian receives state funding and has caregiv- case Brian was hospitalized with the virus. I was ers who go out with him in the community. He horrified to learn that the form had to be filled also has a social worker and a nurse that check out because I would not be allowed to go into a in on him regularly. As COVID-19 began to spread, the workers could no longer We had no answers and wondered come into our home, and many of the activities he enjoyed shut down. In early how long we could go on like this. April, HomeGoods closed, and Brian One day, Brian hung a sign on the could no longer work at one of the farms. His life came to a screeching halt, and fridge that asked us to text him if he wanted to know when things would return to normal. So did we. One of Brithe governor called with information an’s preferred activities in the beginning about a vaccine. It hung there for of COVID-19 was to make lists of what he would do when it ended. He even months. Somehow, we muddled posted it on Facebook. Many friends through as a family, but it was told us they felt like Brian but hesitated to admit it. heartbreaking to watch Brian Brian knew about COVID-19 and started to follow the daily rates of infecregress. tion on social media. He practically bathed in hand sanitizer, stockpiled disposable gloves and hoarded masks. He created his hospital with him if he needed care. One question own personal protective equipment station in a asked the following: “If while you are in the hospital you can’t corner of our kitchen. It includes boxes of disposable gloves, more than 15 masks and a handwritten breathe on your own, do you want a machine to note that reads “PLEASE DO NOT TOUCH MY help breathe for you? “Do you want it at all? BLUE MASKS WITHOUT ASKING ME ON THE “Do you want a trial to see if it is helping? Do PHONE FIRST PLEASE.” Everyone in our family knows better than to ignore this request. Brian you want it for as long as is needed?” The next question asked if he wanted his docdid not come within 6 feet of anyone for a year and never left the state. He asked us every day if tor to try to restart his heart if it stopped. I cried as I filled out the form. there was good news and wanted to know when When Brian was in close contact with someCOVID would go away. We had no answers and wondered how long we could go on like this. One one with COVID-19, we reached out to a medical day, Brian hung a sign on the fridge that asked us provider for advice. She knew he had autism and to text him if the governor called with information still insisted that he isolate and let us know his about a vaccine. It hung there for months. Some- symptoms. There was no way that would be poshow, we muddled through as a family, but it was sible. Instead, the whole family quarantined for eight days. Thankfully, everyone tested negative heartbreaking to watch Brian regress. Fortunately, we could use telehealth services twice. We signed up for a new doctor the next to stay in touch with Brian’s doctors. He always week. He happens to be the parent of a son with looks forward to his appointments and did sur- autism. Brian met with him in person and told us prisingly well with Zoom appointments. It was he likes his new doctor. No small victory. Other friends shared their own struggles. reassuring to discuss our concerns about Brian’s changes in behavior and struggles with being at Some of them had children residing in residenhome with his psychiatrist. Brian could articulate tial settings. These parents were unable to visit his frustration with the pandemic, and his docthem for months. Others learned that their chil-

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dren had COVID-19 but could not see them due to autism, learned that a staff member had tested visitation restrictions. One friend brought her son positive for COVID-19, they opted to quarantine home from a residential program out of fear that if with the students with autism at the residence he became sick, he could not survive due to other for eight days. Melmark parents delivered meals medical conditions. When day programs closed, every day and organized a car parade to celebrate parents had to create their own programming for the end of quarantine.1 their adult children. One mother I know started In March, a COVID-19 vaccination clinic was a daily baking program in her house for her son. hosted at the Lincoln Financial Field in PhiladelThey created some beautiful cakes together. My phia by the Eagles Autism Foundation in partfriend’s son could not accept the fact that movie nership with Divine Providence. Vaccines were theaters were closed. In the beginning of the administered to more than 1,000 individuals with pandemic, he called his favorite theater at least autism and their families. Doug Lurie, owner of 30 times a day, hoping someone would answer. the Philadelphia Eagles, has a brother with autism His mom took him to the theater and helped him and formed the Eagles Autism Foundation to raise accept that theaters were closed and that no new money for research and programs to help better movies were being shown. understand autism.2 There were also moments of grace. When vacMass Advocates for Children, a child advocines became available, prioritization for adults cacy firm in Boston where I do pro bono legal with disabilities was not clear-cut. Brian saw his work, created a COVID-19 Information Clearing friends with their vaccine cards on Facebook and House for families trying to ensure their children told me I was a bad mother because they had vac- receive the educational services they are entitled cines and he did not. He did not understand why to. It started virtual monthly chats as a way for certain friends with autism were vaccinated but parents to connect with each other and to discuss he was not. Quite candidly, neither did I. Dur- concerns with special education experts and lawing one of my more difficult afternoons, I called yers. Mass Advocates for Children also provides a government official to ask why my son could guidance to parents about compensatory services not get vaccinated. We spoke at length about the and summer school. vaccine rollout, and she explained that she would And yet, families continue to struggle. Many continue to advocate on behalf of adults with dis- day programs have not reopened, and those that abilities. Although I didn’t change the outcome, I have operate at half capacity and cannot take parfelt listened to as a parent. ticipants out in the community. There are also After I hung up, I reached out to my friends staff shortages. Many of the jobs that adults with Maura Sullivan of the Arc of Massachusetts and disabilities had before the pandemic no longer Michael Borr of Advocates for Autism of Mas- exist. Social outings could not resume until more sachusetts (AFAM). When I He did not understand why certain explained my frustration with the prioritization process for friends with autism were vaccinated but individuals with intellectual disabilities and their parenthe was not. Quite candidly, neither did I. caregivers, they reached out to members of the legislature and drafted letters people are vaccinated. It is difficult for adults with to government leaders seeking a solution. Their disabilities to fully understand why things cannot efforts resulted in more than 3,000 letters being return to normal. sent to Baker and Secretary of Health and Human I am happy to report that Brian got vaccinated Services Mary Lou Sudders, asking for vaccines at a Council on Aging Clinic in a town nearby. for adults with intellectual disabilities. Eventu- After receiving his first shot and waiting for 15 ally, the prioritization was modified, and more minutes to pass, he called his father on his cell vaccines were available. phone and told him he finally got his life back. Schools and programs that work with individ- Later that day, his sister and her fiance came for uals with autism often went above and beyond the dinner to celebrate their engagement. He had call of duty. When staff at Melmark New England, asked her to marry him a few days before. They a day and residential school for students with had called family members to share the news but

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had not made any public announcement. While sitting together talking about wedding plans, they asked Brian to share their news on Facebook. Brian was the ideal choice as he has quite a social media following and posts regularly on Facebook and Instagram. His posts are known for lots of emojis, and he lives for likes and comments. He posted a beautiful photo of them together with the words “Congratulations to my sister and her future husband and my new brother-in-law. Cheers to you both. Wish you lots of happiness and love. So very excited about this news.” It was wonderful to have good news to share. Many people agreed. Brian’s post received 142 likes and 54 comments. It was a good day for our family.

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

ANN E. GUAY has worked as an attorney in private practice and was a policy analyst at Massachusetts Advocates for Children, where she

now volunteers as a pro bono attorney for military families. She serves on the executive committee of Advocates for Autism of Massachusetts and the boards of several autism programs for adults. NOTES 1. Genevieve DiNatale, “Melmark Quarantines Students with Staff 8 Days After Coronavirus Exposure,” Andover Townsman, April 21, 2021, https://www.andovertownsman.com/news/local_news/melmark-quarantinesstudents-and-staff-8-days-after-coronavirus-exposure/ article_e8fc4a2a-04a1-5ad4-af9a-009154baed7d.html. 2. Maddie Hamman, “At the Eagles’ Stadium, a COVID19 Vaccination Clinic Designed for People with Autism: ‘We Need to Meet Them Where They Are,’” Philadelphia Inquirer, March 27, 2021, https://www.inquirer.com/ health/coronavirus/covid-vaccine-philadelphia-autismdisabilities-eagles-20210327.html.

Courage in Uncertainty 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 uncertainty, 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 courage in the past days? THINK FOR A MOMENT.

In these days of uncertainty, where have I found courage?

(Pause to consider) DWELL in the courage 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.

Our God himself goes before you and will be with you; he will never leave you nor forsake you. Do not be afraid; do not be discouraged. DEUTERONOMY 31:8

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Upcoming Events from The Catholic

Health Association

Anti-Human Trafficking Networking Zoom Call July 13 | Noon ET

Webinar: Advanced Issues in Sponsorship – Session Five: Initial and Ongoing Formation of Sponsors July 14 | 2 - 3:30 p.m. ET

Deans of Catholic Colleges of Nursing Networking Zoom Calll July 20 | Noon – 1 p.m. ET

We Are Called – Confronting Racism to Achieve Health Equity Conversation Series IV

July 28 | Noon – 12:30 p.m. ET

Global Health Networking Zoom Call Aug. 4 | Noon – 1 p.m. ET

Webinar: Advanced Issues in Sponsorship – Session Six: Ministry Identity and Sponsor Assessment

Earn your advanced degree in

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

Courses are taught face-to-face on campus or through online learning for busy professionals

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.

The curriculum provides expertise in clinical ethics, organizational ethics, public health ethics and research ethics, with clinical rotations in ethics consultation

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

Doctoral students research pivotal topics in healthcare ethics and are mentored towards academic publishing and conference presentation

Aug. 11 | 2 - 3:30 p.m. ET

Questions? 412.396.4504 or chce@duq.edu

See Health Progress online at

chausa.org/publications/ health-progress

chausa.org/calendar

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CHRISTUS Health Strikes Balance to Provide Safe, Loving Support for Patients DEBI PASLEY MS, RN CHRISTUS Health Senior Vice President and Chief Nurse Executive

became a nurse because I wanted to serve patients, and I became a nurse leader because I wanted to serve nurses. But never has a situation presented me more opportunities to do both than the COVID-19 pandemic.

In spring of 2020, as the pandemic escalated changes in our world, early directives from emergency management agencies and local and state governments moved to limit visitors in hospitals. Within days of shutdowns and other public health measures, local hospital leaders within CHRISTUS Health received these requests to prevent all but employees from being in our hospitals. Little did these agencies know the complications that would create. CHRISTUS Health quickly recognized the inconsistency of isolating patients, who trusted us for their care, from their essential support persons and how that choice would keep us from the ability to fulfill our mission. Patients tell care providers who their essential support persons are. Generally, it’s those who are closest to the patient who can provide physical and emotional support during and after illness. But policies to keep patients’ families and loved ones out of hospitals, intended to reduce infection spread, led to difficulties. Not only did these policies often cause fear and anxiety for our patients and their loved ones, they took a toll on our caregiving employees as well. In addition to the heightened workload while caring for patients who were alone, nurse ethicist Georgina Morley and her co-authors outlined in an article in the Hastings Center Report the impact of moral dis-

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tress that grows from the absence of essential support persons in health care environments.1 The presence of loved ones has proven to improve mental status, decrease length of stay and improve safety in the acute care environment. Not only that, but we received feedback from critical care physicians and employees that it was more difficult to relay the medical reality to families who could not be at the bedside and witness their loved ones’ struggles. We realized we had clinical, ethical and mission-driven reasons to allow loved ones who provided patients with essential support into the facility, so we had to find a better way to provide care and support while maintaining a safe environment.

TEAM APPROACH TO COMMUNICATE WITH FAMILIES

There were times when we needed help. At the height of the surge, physicians, nurses and other clinicians couldn’t always be there to ensure regular communication with anxious family members. Our highly trained teams were busy managing care and preventing death. That’s why we developed a plan for patient care associates, our spiritual care team and others to manage the important task of open communication during the busiest of times. Each care team designed what would work for them based on their available resources. Even then, however, reevaluating protocols and

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FAMILIES AND THE PANDEMIC

expanding our visitor policy became an urgent need for our entire system.

NUANCED VISITOR POLICIES TO PREVENT ISOLATION

We engaged CHRISTUS Health’s Advocacy team, which works on legislative matters, to evaluate state orders on the topic. We soon recognized that none of the executive orders in our states were absolute in those limitations. The wording around “essential support persons” gave us the flexibility to ensure safe support from key loved ones during hospital stays. This led us to categorize patients

based on the nature of the care they were receiving. Life-changing events, such as birth and end of life, demanded more latitude. More high-risk situations, such as a COVID patient receiving aerosolizing procedures, required greater caution. CHRISTUS revised the guidance in its policies regarding the presence of essential support persons (Table 1). Implementation of the guidelines was met with caution in some ministries. However, patient and caregiver feedback has reinforced the importance of advocating for our patients and families.

TABLE 1 Maximum number of people allowed in the room at any given time

Essential support person (ESP)1

All other visitors

COVID under aerosolgenerating treatment or procedure

Tele-visitation

Up to 2, only during compassionate care exceptions

COVID and no aerosolgenerating treatment or procedure

1 in the room at a time

Tele-visitation

Up to 1 (if compassionate care exception, up to 2)

End of life and other compassionate care exceptions2

1 in the room at a time

Up to 3 visitors in the room at a time, no limit on number of visitors per day

Up to 4 (if COVID, limited to 2)

Critical care units and emergency departments

1 in the room at a time

Tele-visitation

Up to 1

All other situations (inpatient, pediatrics/adult, labor & delivery, same-day procedures, appointments, etc.)

1 in the room at a time

Up to 1 visitor in the room at a time

Up to 2

Type of Visitor

Note: All visitors and ESP must complete visitor screening and comply with universal masking regulations according to current screening and masking guidelines. When visiting COVID patients, visitors and ESP must also comply with the use of personal protective equipment as specified by policy. 1. Per stay, each patient is permitted to designate one or more essential support persons. The identification process must be coordinated through admission or the registration desk. In some facilities, each ESP receives a visible wristband. 2. End of life and other compassionate care situations must be evaluated by the house supervisor or administrator on call on a case-bycase basis.

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STAFF SHOW EXTRAORDINARY HEART

Family members rely on our comfort, something that our CHRISTUS nurses, like Betty Rutherford from Corpus Christi, Texas, fully realized during the pandemic when she cared for entire families devastated by last year’s surge of the virus. She didn’t just work at the top of her profession to prevent death. She worked to prevent suffering by being there for her patients when their families were not allowed inside the hospital hallways. She was with patients and then held family members when they lost loved ones. As her experience was replicated time and again, we began searching for a better way to ensure that no one we serve had to suffer in isolation. Critical care nurses like Nanette Foster from Shreveport, Louisiana, fought to save so many lives and to make sure no one would be forced to be alone. Spiritually and emotionally, it took a toll on all of us. That’s why, as clinical leaders, we owe it to ourselves and others to make sure that we make family visits and communication the standard of exceptional care. Many CHRISTUS employees experienced the myriad communication and visitation challenges wrought by COVID-19. Rosie Tijerina, who manages a CHRISTUS print shop, lost her 27-year-old grandson who was hospitalized an hour away from the nearest CHRISTUS facility. She spent weeks with the added stress of having to wait by the phone for terrible updates about her grandson until he succumbed to COVID and passed away. Coordinating communication between family members and critical patients resulted in additional stress for our staff as well. Charge nurses would dress in protective gear and use laptops and cell phones to help loved ones say goodbye, many times over FaceTime. The family members had to watch via a screen as a mom or dad slept in a hospital bed. To witness them taking in the last moments of having a parent before they passed away changed everyone’s perspective on the right and wrong way to treat those we serve. Isolation in health care should never be tolerated.

BALANCING NEEDS

While some were initially concerned about letting relatives or the support person into health care settings during the pandemic, we knew that we

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Healing is not always about physical restoration; it is also about spiritual and social repair. could keep our caregivers safe through the use of personal protective equipment (PPE). Our supply chain colleagues also secured an adequate supply of PPE to allow us to use it protect the essential support persons of our patients with COVID-19. We explained that enabling safe family presence is rooted in compassion, one of our core values. After all, healing is not always about physical restoration; it is also about spiritual and social repair. Allowing essential visitors to be with our patients allows mutual compassion between patients and family. We invited clinical leaders and front-line staff to evaluate what they would want for their own family members and the efficacy of our guidelines in stemming the spread of infection and COVID-19 within our facilities. In the end, it became clear that our mission, our patients and their families — as well as our associates and physicians — needed the support of visitors and essential support persons. We’ve implemented this expanded policy at all our U.S. CHRISTUS facilities and already are hearing that it has made a difference. As a system with a calling to extend the healing ministry of Jesus Christ, it’s easy to imagine Jesus working right alongside our care providers, sitting next to the beds of our patients and comforting their families. We’ve known Jesus has been here all along, and now we’re glad to share that experience and that compassion with our visitors and support persons as well. DEBI PASLEY is a system senior vice president and chief nurse executive for Irving, Texas-based CHRISTUS Health.

NOTE 1. Georgina Morely et al., “Covid 19: Ethical Challenges for Nurses,” Hastings Center Report 50, no. 3 (May 2020): 35-39, https://doi.org/10.1002/hast.1110.

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Finding Our Way, Together LAURA RICHTER, MDiv SSM Health, Mission Integration Vice President

hen people asked me how I was doing during the pandemic, I found myself frequently turning to the famous first line of Charles Dickens’ A Tale of Two Cities. With each articulation I offered examples, illustrating how apt the statement was for my family. It was the best of times. My girls and I rocked certain parts of our COVID existence. We consider ourselves a resilient bunch and met the initial changes with great enthusiasm. The shift to homeschooling offered opportunities for picnic lunches and nature walks to break up our Zoomfilled days. We developed new rituals to navigate the challenging times and became adept at hosting socially distant backyard gatherings. We expanded our backyard flock with six baby chicks, planted a garden, adopted two rescue kittens and invested love and hope in our little “farm.” Mommy loved the Zoom cocktail hour, the girls scheduled online playdates and eventually virtual meetings were the next best thing to being in-person. We spent more time together and increasingly appreciated everyday activities. The opposite also was true. As a week of homeschooling became a month, we lost interest in the flexible structure and Zoom reality. Just as we adjusted our routine, things changed: the school schedule, the online platform, where we could go, what we could do, our sitter’s availability and how we balanced safety with keeping our house stocked and running. Each housemate neared her edge multiple times during confinement. One child burst into tears on a science nature walk, declaring she hated COVID and all its repercus-

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sions. The other experienced utter despair over her wardrobe as she transitioned to hybrid schooling in January. We sobbed in the vet’s office as we said goodbye to three young chickens who didn’t make it. I said, “I don’t know how much longer I can do this” several times just in the last month. Things that once caused mere frustration brought us to tears instantaneously. The Dickens quote is cited often for a reason. It quickly sums up how a time can be both deeply challenging and contain joy. It became my organizing principle for the pandemic and a way for me to sort experiences. As I repeated it to others, there was nodding of heads. Others also had found moments of great joy, connection, creativity and relief during the pandemic. Simultaneously, individuals felt they were nearing the edge of a precipice. Communities and countries were rocked by the same pandemic and the global focus on injustice and disparity. As an adaptive species, many learned to manage what initially were inconceivable situations. Then new things emerged, further testing our resilience; we struggled to find health and happiness. Health and happiness. These were things I thought I knew and could pursue. But through the pandemic, they were elusive, continuing to evolve as our reality has. Just as I think we are approach-

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FAMILIES AND THE PANDEMIC ing one or the other, things change, and we feel lost again. This has invited me to a new level of theological reflection on aspects of health and health care. I engage in this reflection from where I am — a single mother of young girls, a health care executive and a community member — all of which shape my reality and reflection. I’ve become more aware that happiness can be a difficult, if not untenable, pursuit if one is unemployed, homeless or food insecure. What I realize, now more than ever, is one’s health and happiness are truly intertwined in the web of our lives— our family relationships, workplaces, schools, communities, our country and even our world. For individuals and families to flourish, change is needed at the individual level, but also within health care systems, our communities and world. There are a few reminders that may help us as we engage in this pursuit.

HEALTH TRANSCENDS THE BODY

Once they were identified, we had to determine who could best address the issues, and there was no common solution. For my oldest daughter, returning to the counseling nonprofit for children of divorced families made sense. My younger daughter’s issues launched us on a pinball-like trajectory that included our pediatrician, several school personnel and now a psychologist who can hopefully illuminate issues with some psychoeducational testing. After a failed attempt with Noom, I want a health coach who encourages healthy eating, devises workouts and holds me accountable. For each family member, there was no single provider — no holistic solution — to help us, nor did many of the resources we tapped exist in the traditional health care sphere. Though we are finding our way, the process has been disjointed, frustrating and siloed. How we would have welcomed a common coordinator to help us sift through issues, identify what to address and then direct us to the appropriate provider or resource. Could resolution come faster if providers were in conversation with each other instead of each being a separate conversation or visit? What if wraparound services happened at one location, allowing us to pursue health and

Catholic health care has long recognized that health and healing are about more than the body. Gospel stories show Jesus tending to more than physical ailments. He sees a person in their fullness, mends broken relationships, brings the outsider back into the community. The Ethical and Religious DirecFor individuals and families to flourish, tives for Catholic Health Care echo this, recognizing the mental, social change is needed at the individual and spiritual elements of health. level, but also within health care We practice this in our facilities, integrating holistic care as well as systems, our communities and world. honoring the web of relationships and support that provide hope and healing. But oftentimes, individuals and organiza- happiness? That feels far off, but having more contions don’t address social and emotional aspects nected and holistic services is a good first step in addressing our health in ways that could lead to of health until some part of the body goes awry. Each member of my household experienced greater happiness. As I detail our journey through these months, health challenges during the COVID pandemic. My older daughter, confronted with all the I am aware others suffered more acute anguish. changes wrought by the pandemic and a new Tragic disconnects happened as loved ones were serious relationship in her dad’s life, experienced separated and could not say goodbye. Hospital and crying fits and sleeplessness. My younger daugh- nursing care policies, as well as travel restrictions, ter’s struggles with school evolved into anxiety, trumped social and emotional needs in the name emotional outbursts and physical symptoms that of safety. Some lost family members and friends to landed us in the doctor’s office. After packing on COVID, and others will experience challenges for the COVID 10, then 17, then more, I find myself in months after recovering. Exhausted staff lacked a place where my clothes and health metrics need energy to engage mental health needs because adjustment. Each of these bodily manifestations being present at work drained what little energy have a whole host of mental, emotional and social they had. Many staff will experience post-trauaspects, but I wasn’t proactive in addressing them matic stress disorder for years to come. In all of these cases, we must remember a until the bodily symptoms presented.

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coordinated approach that focuses on all aspects of health can better lead us to healthy and happy individuals and communities.

BANDING TOGETHER FOR SOLUTIONS

ing Boxes that popped up in strategic locations across town, providing places where people could pick up donated food resources and personal supplies. Some solutions created problems in the community: neighbors complained the Blessing Boxes encouraged homeless people to loiter at bus stop and parks. Overall though, creativity surged, connections developed, and we came together. But will these resources vanish when the pandemic passes? What happens to the families who still need support? Might we need to deepen our concept of community if we want individuals and families to flourish?

Our COVID experience not only highlighted the interconnectedness of health needs, but also our reliance on others in ways previously unexperienced. Beyond the imparting of intellectual knowledge, education also provides healthy meals, connection with social services, exercise, habit development and socialization. All are important parts of the school experience, contributing to overall health and happiness. All were gone overnight. I struggled to complete my own WE CANNOT FORGET WE BELONG TO EACH OTHER work and shepherd two children through online Though some understood that working together assignments. My younger daughter fell behind was critical to weathering the pandemic, not all quickly in kindergarten without reading support, were familiar with the concept of the common and her anxiety increased without regular social good. Some hoarded supplies and overused health services. Now in first grade, we suspect learn- care resources. There was varied understanding ing disabilities may be present, but that’s hard to of essential services. Many at the margins found detect via Zoom or hybrid learning, when teach- themselves without work and feared loss of housers can’t spend as much time with children. As the ing, but landlords also had bills to pay and busipandemic months wore on, we, like many families, broadened We must remember a coordinated who we turned to for support. approach that focuses on all aspects of On the community mom blogs, people discussed food health can better lead us to healthy and insecurity, lack of social services and increasing depreshappy individuals and communities. sion. Parents, disproportionately women, were stepping out of the work- nesses had commitments. Some prized personal force because education also serves as child care. freedom over community safety. Existing health Needs were palpable and online conversations disparities translated into racial and ethnic minorescalated as members approached topics like the ity groups being disproportionately affected by return to school from very different perspectives. COVID. At times individual primacy won the day Stress plagued many, including those balancing and disparities raged. If our communities were working from home and homeschool, those who graded on how well they treated the most vulnerfeared for their safety daily and the suddenly job- able among them, many would have failed. less now struggling to purchase needed supplies In an opinion piece in The New York Times, and maintain housing. Health and happiness were David Brooks claimed we would need to move so intertwined, and it became clear that everyone beyond social connection to social solidarity. He needs help at times and any measure of kindness stated: “Social solidarity is more tenacious. It’s an could go a long way. active commitment to the common good … this Existing community resources shifted, and concept of solidarity grows out of Catholic Social new ones emerged. The community center cre- Teaching. It starts with a belief in the infinite digated learning spaces during parents’ work days nity of each human person but sees people embedwhere children received online schooling sup- ded in webs of mutual obligation — to one another port. A neighborhood grassroots effort sprung up, and to all creation. It celebrates the individual and using crowd sourcing and other ways to provide the whole together, and to the nth degree.” If we multiple types of assistance. Schools continued to were to emerge from the pandemic together, we provide free lunch while not in session and other could not forget others’ health and happiness food-related resources emerged, including Bless- were inextricably connected to our own.

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FAMILIES AND THE PANDEMIC To achieve health and happiness, everyone had to practice solidarity. People needed to stay home and take precautions, and businesses had to reinforce guidelines. Family gatherings and planned vacations had to pause, preventing further spread of the virus. Consumers could buy only what was needed. Great creativity and compassion emerged during this time as examples of how we could care for one another. Ordering takeout from local restaurants preserved employment. Regional groups stepped up to bridge gaps in services, food inse-

To achieve health and happiness, everyone had to practice solidarity.

to provide housing for health care workers who couldn’t risk infecting their families, and setting up food and supply options became part of employee support. As individuals and communities recognized their interdependence, connections emerged, and health increased on many levels. More work is needed to extend connections and further evolve the sense of common good, addressing disparities that surfaced during the pandemic, allowing health and happiness for more community members in the future.

CONCLUSION

curity and housing. When the common good was clearly in focus, health and happiness became increasingly attainable for more people. Health care had to pivot as well. Providers had to look beyond their patients and market share to prioritize community need. Non-emergent services had to step aside to accommodate the surges. Vaccines had to be administered to the most vulnerable first, meaning health care systems had to abide by guidelines and individuals had to wait their turn. Serving the poor and vulnerable translated into identifying at-risk zip codes, providing outreach for vaccine registration and sending vaccine vans beyond service areas. Health care wasn’t only a provider, but an employer as well. Identifying and subsidizing childcare resources for parents, creatively working with local hotels

As the pandemic subsides, I wonder what the future will look like. Reconnecting with those I love and our first vacation will be joyous events. But disparities still exist, and things may return to their pre-pandemic state. What remains powerfully present to me today is health and happiness are intertwined. If we are to have healthy and happy families, we — individuals, communities and health care providers — must pay attention to all facets of health. Our view of health must include mental health and wellness as well as the basic human needs that influence our lives. Hopefully if we can remember health transcends the body, and we belong to each other, health and happiness can be found. LAURA RICHTER serves as a mission integration vice president for SSM Health, where she oversees formation efforts and other mission initiatives.

QUESTIONS FOR DISCUSSION Laura Richter, mission integration vice president for SSM Health, writes that the pandemic strengthened her realization that health and happiness are intertwined, and that we need to continue to take a holistic approach to body, mind and spirit health. 1. Reflect for a few minutes on your own shifting emotions during the COVID-19 pandemic. Have you experienced more of some emotions than you normally do? Think about which ones. Have there been times when anxiety, fatigue or grief made it hard to find happiness in 2020-21? Was there a bright spot or new realization that allowed you to shift toward happiness? 2. She writes about how health care had to pivot during the pandemic. What good and lasting changes have come during the past year when it comes to providing health care? Have you seen new partnerships, new ways of working that are efficient and achieve better outcomes? What new approaches would you most like to see remain operational in health care? 3. Has your understanding of community shifted because of the pandemic? How so? What aspects of community can be effectively harnessed to reduce disparities and divisions?

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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 !

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Letting Empathy Guide the Way

How One Social Service Organization Adapted During the Pandemic

SR. LINDA YANKOSKI, CSFN, EdD President and CEO, Holy Family Institute

“W

e are in this storm together, but we’re all in different boats.” A member of my staff quoted those words from a Vatican document in a recent meeting, and they have remained in my mind ever since. These words eloquently express why it’s so vital to let empathy guide our decisions as we navigate the effects of the COVID-19 pandemic — and they are an especially poignant reminder for organizations like Holy Family Institute that manage social services, education and other essential resources for families facing difficult situations. Our goal since the beginning of the pandemic — and since our founding more than 100 years ago — has been to help families stay afloat, weather the storm and come out better equipped to deal with whatever harsh weather may come next. Holy Family Institute was founded in Pittsburgh’s Emsworth neighborhood in 1900 by the Sisters of the Holy Family of Nazareth. Originally an orphanage, we have adjusted to changing social conditions and changing understandings about what works best for children and families. We now provide a wide range of services to children and families. These services include mental health and drug and alcohol counseling, special and alternative education, family counseling, energy assistance, behavioral intervention and prevention programs, student assistance programs and shelters for unaccompanied minors. Our multiple program options provide many children with the “wraparound” services that life challenges require. Our latest initiative, Nazareth Prep, is an independent Catholic high school that focuses on college and career readiness for students who can’t afford private school tuition.

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EDUCATING DURING A PANDEMIC

Education comes with its own set of challenges, even without the added stresses of a global pandemic, so you can imagine the year our students have had. Navigating from in-person learning, to online learning, to a hybrid model, then back to in-person learning, has demanded far more flexibility from students and teachers than any “regular” school year. When we abruptly switched to virtual classes last year, our most urgent challenge was bridging the technology gap. Many of the students who attend our Specialized Learning School, a referral-based school for students with behavioral and academic challenges, did not have computers or internet access. Teachers delivered and mailed lesson packets to students so they could keep up. Over time, with our own funds and additional resources from the Pennsylvania Department

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FAMILIES AND THE PANDEMIC

of Human Services and the Carnegie Library of several weeks to flatten the curve of infection, Pittsburgh, we distributed laptops and hotspots school counselors made frequent calls to famito seamlessly connect students with their teach- lies, encouraging students to keep attending and engaging with virtual classes. The overwhelmers and classmates. Unfortunately, even the latest and greatest ing response staff heard from parents? “We’re not technology cannot solve all challenges created worried about school; we’re worried about putby online learning. Attendance rates dropped ting food on the table.” As soon as we heard about this urgent need, at both schools as our students — particularly young children unaccustomed to sitting in front we committed ourselves to being part of the soluof the computer all day — struggled to focus in the tion. Our staff adapted daily to get nutritious food virtual environment. Online learning also eliminated one of the most While I applaud our teachers and essential safeguards we provide to students for their efforts to adapt our students. Normally, if a student shows signs of distress or abuse, their to the challenges and restrictions of teachers can initiate an interventhe pandemic, it has become evident tion process. With students at home, it became much more difficult for that virtual learning cannot replace teachers to monitor their well-being and identify problems. the social and emotional benefits of While I applaud our teachers and attending school in person. students for their efforts to adapt to the challenges and restrictions of the pandemic, it has become evident that virtual into the hands of families. Staff collected donalearning cannot replace the social and emotional tions with a local church partner and delivered benefits of attending school in person. Thank- the items to students’ doorsteps. They connected fully, both Nazareth Prep and the Specialized families with other resources like food banks, diaLearning School have kept students in the class- per banks, donations from World Vision (a nonroom for most of the pandemic, only making the profit humanitarian organization), unemployswitch to online learning temporarily during case ment benefits, and rent and energy assistance. High school students at our Specialized Learnspikes. Although the last year has presented oncein-a-lifetime challenges, it also has reinforced the ing School — whose work opportunities had been importance of classrooms where students can curtailed due to the pandemic — volunteered after school to pack bags and help with distribuplay, learn and grow in camaraderie. tion. We also created the Blessing Bags program, which provides food for students to take home to RESPONDING TO FOOD INSECURITY Even if quality education is available, how can we their families over the weekend or during school expect a hungry child to focus on his or her home- breaks. It was a welcome encouragement to watch work? Throughout the pandemic, we have seen an our community mobilize so quickly to meet this increase in the number of families lacking access most critical need. to adequate food sources. Many of the households in our community have lost some or all of their ADDRESSING MENTAL HEALTH CHALLENGES income, forcing them to make an impossible deci- Another central challenge of the pandemic, which sion: should they prioritize paying for bills, rent, we encountered among clients of all ages, was food, medication or transportation? As childcare its negative impact on mental health. Accordcenters and schools closed for weeks at a time, ing to a recent study published in The New York forcing parents to stay home from work, families Times, a quarter of 18- to 24-year-olds said they grew even more vulnerable. had seriously considered suicide last year.1 Our Most students at our Specialized Learning counseling staff has witnessed a moderate rise School rely on the free and reduced lunch pro- in suicidal ideation in teenagers and preteens gram to provide an important part of their daily and a significant rise in depression and anxiety nutrition. When we shut the school down for as a direct result of isolation, pandemic-related

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To encourage a mindset of self-care, we’ve stress, and the loss of important social opportunities provided by sports, extracurricular activities, borrowed a mantra from airline safety, remindanticipated social events and regular contact with ing each other often to put on our own “oxygen friends. These mental health struggles exist inde- masks” before helping someone else. We encourage every employee to do something daily (such pendent of income level. In-Home Family Services Counselors, who as meditating, taking a walk or reading 10 pages in help parents provide a safe and healthy environ- a book) to promote their own physical, mental and ment for children while dealing with abuse, addic- emotional health. I began a Friday Feelings reflection sent to all tion, attachment disorders, grief or mental health issues, continued to visit families at home with team members. Each week I tried to find words to safety protocols in place. In addition to these uplift, console and challenge: uplift spirits tired routine check-ins, staff regularly employed com- of Zoom meetings, console team members who munication and coping therapies to identify new lost loved ones to COVID, make suggestions to stressors, address issues as they arose and con- relieve stress and loneliness, and challenge racial nect families with additional resources if needed. bias after the murder of George Floyd. I received Mental health counselors also have juggled such a good response that I plan to keep this up these increased needs with the added challenge even after the pandemic ends. of virtual therapy sessions. They have shown impressive flexibility and creativity in keeping FACING UNPRECEDENTED CHALLENGES AND LOSS clients engaged, especially in virtual therapy ses- It has been a year of both unprecedented chalsions with young children. During these sessions, lenges and unexpected solidarity. While I have staff has used art therapy and online games to put been, and continue to be, uplifted by the many clients at ease and encourage communication. For examples of resourcefulness and kindness, I have example, one counselor asked a distraught young also been a firsthand witness to unique hardships child to go on a scavenger hunt to find something and profound grief in our community. It feels as that brought her comfort in her house. She came if COVID-19 has left no aspect of life untouched – back with a favorite stuffed toy, which her coun- not our day-to-day routines, not our plans for the selor used to help her to learn vital self-soothing future, not even our relationships with the people skills. While this pandemic has certainly chal- we love most. lenged each of us in different ways, these everyday encounWhile this pandemic has certainly ters remind us of the disproportionate harm it has dealt to the challenged each of us in different ways, most vulnerable members of these everyday encounters remind us our community.

SUPPORTING OUR STAFF

of the disproportionate harm it has dealt to the most vulnerable members of our community.

Caught up in the rush of adapting to virtual counseling sessions, driving to in-home appointments, and developing online homework assignments, we knew that prioritizing self-care was becoming more difficult — yet also more important — than ever before. Before the pandemic, home was a safe space, a refuge from the stress of the job. But the shift to remote work and telehealth sessions has kept that stress lingering around the kitchen table after the workday ends. Staff members have worked harder than ever, handling their own pandemic-related insecurities while supporting clients who were under even more stress than usual.

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Last year, a student (who we’re not naming to protect his anonymity) transferred to Nazareth Prep as a freshman in the midst of the pandemic. Only a few months after in-person classes began, he lost both his grandfather and his mother, who was his primary caregiver. It was an unthinkably heartbreaking situation. The student, who now lives with his uncle, has shown great resilience and strength despite his profound grief. I was so proud to see Nazareth Prep’s staff and the entire student body rally around him. The

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school took up a collection to ease the financial burden of transitioning to a new living arrangement, he was provided additional academic support, and teachers maintain contact with his family to ensure that his needs are being met both at home and at school. All of our students at Nazareth Prep, whether they are facing hardships or not, have access to counseling, supportive adult role models, and expert advice and guidance from career coaches, faculty, and internship site mentors on post-secondary pathways. But we have found that engaging more with students’ parents and guardians over the past year, especially when students are on a remote learning schedule, has been critical to attendance, assignment completion and student engagement. This increased communication has been the silver lining of the tumultuous academic environment of the past year.

LOOKING FORWARD WITH RESILIENCY AND HOPE

At this writing, the vaccine is rolling out rapidly across the country and making incredible progress in our home state of Pennsylvania. I am hopeful that before too long, we will have achieved population immunity and returned to some level of normalcy. Recently, the Head of School at Nazareth Prep,

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Rita Canton, was stopped in the hall by a student who told her, “I’m so happy to be here.” It is heartening to hear our students’ optimism and joy, to see them display resiliency and excitement about learning, and to join them in their youthful hope that things will continue to get better. Our work to overcome the challenges of the pandemic and its impact on our most vulnerable students and clients must and will continue. I have faith that our staff is prepared for the task. I am confident that they will continue to sign in, show up and make a difference in the lives of our neighbors every day. SR. LINDA YANKOSKI has served in an executive role with Holy Family Institute for more than 40 years, including 30 years as president and chief executive officer. A $29 million nonprofit organization with 360 employees, Pittsburgh-based Holy Family is among the region’s largest social service/educational organizations.

NOTE 1. Dr. Perri Klass, “Young Adults’ Pandemic Mental Health Risks,” The New York Times, August 24, 2020, https:// www.nytimes.com/2020/08/24/well/family/youngadults-mental-health-pandemic.html.

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Financial Programs For Our Workers The Ultimate Return on Investment

EMILY STEVENS, MBA, MSW, LCSW-BACS and COLETTA C. BARRETT, RN, FACHE Our Lady of the Lake Regional Medical Center

OVID-19 exacted a toll not just on our physical health but our financial well-being as well. In some cases, the pain hit close to home, leaving health care workers doubly stressed. Some faced the fear of contracting the virus at work while unable to pay bills at home. To stay afloat, they had little option but to turn to short-term, high-interest loans. But through multiple expansions of an existing microlending fund and participation in an innovative advance paycheck program, Franciscan Missionaries of Our Lady Health System (FMOLHS) has helped some members of its workforce gain–or regain–financial footing. The system laid the foundation for financial assistance in 2018, when Our Lady of the Lake (OLOL) Regional Medical Center partnered with Catholic Charities Diocese of Baton Rouge to establish The Faith Fund. To help individuals overcome their reliance on high-interest payday loans, The Faith Fund offers lower interest rates as well as free financial counseling. This holistic approach enhances financial literacy to help prevent financial instability, establish financial recovery and create financial stability. It can help people out of a vicious cycle, where they may take out loans but then struggle to pay them back due to the fees and interest they’re charged through sometimes predatory practices. (See Figure 1 on the next page.) Following an initial $50,000 grant from the OLOL Team Member Assistance Fund, the program received 70 applications in October 2018 for assistance with payday loans. By December 2018, 398 loans had been approved with a total of $142,528 borrowed. By year’s end, our paid and contract employees had avoided $263,953 in fees and interest payments—money they could invest

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in themselves and their families. All Faith Fund applicants meet with a volunteer financial adviser to complete a financial assessment. Though not all loans are approved, all applicants are offered financial education and one-on-one coaching on budgeting and money management. If approved, borrowers participate in mandatory financial education sessions led by a certified community partner where they develop a budget and sustainability plan. FMOLHS is committed to paying fair and just wages, and has a timeline for moving employees up to a minimum of $15 an hour, but it continues to recognize it can assist with financial need and counseling. Since its inception, the fund has evolved its assistance programs to meet the individual needs of the team and the times. When the pandemic began, the health system was forced to make tough decisions on layoffs, furloughs and reduced (32–hour) work weeks. The Faith Fund responded quickly and established the COVID-19 Faith Fund emergency income stabilization loan program. Through the program, FMOLHS team members could apply for up to $500 a pay period for six,

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FAMILIES AND THE PANDEMIC two-week pay periods. Loan payments had to begin within 90 days of receipt and be paid in full within one year at a 5.9% interest rate. The Faith Fund was created by and had solely supported team members at OLOL, the system’s flagship hospital. The pandemic not only inspired an additional option for financial aid to The Faith Fund portfolio; it also expanded and standardized the availability of financial aid resources to the system, which includes eight hospitals in Louisiana and Mississippi. During this time of rapid expansion, Faith Fund analysts recognized a troubling trend: many team members also relied on high-interest rate credit cards and car loans. The Faith Fund responded by approving a Freedom Loan product to help team members escape these predatory situations. The following story was shared by a financial counselor, with the client’s permission, during a recent Faith Fund Board of Directors meeting. It demonstrates the power of this opportunity: “Over two years ago, an employee of Our Lady of the Lake heard about The Faith Fund and reached out to us for help with payday loans. Throughout the years, she has turned to us for help with multiple financial challenges such as auto repairs, paying off high-interest loans, and even requesting help at the beginning of the pandemic. We have completed multiple financial counseling sessions with her and helped her get through some very difficult times. Recently, she reached out again because she had contracted COVID-19 and her husband’s cancer had returned. She was so overwhelmed. She had fallen back into payday lending debt out of fear that we wouldn’t help her out any more than we had already. She had accessed

FIGURE 1

BATON ROUGE PAYDAY LOAN MARKET DATA Lenders are concentrated in low-income and majority minority communities. Payday loans are taken out for rent, utilities, food and other necessities. Borrowers take out loans against their next paycheck. The average borrower takes out nine loans/year at about $350 a loan. Borrowers have no other options. Lenders argue they are keeping people in their homes and providing a needed service in a competitive market, so why regulate it? SOURCE: Includes information from the Louisiana Budget Project, www.labudget.org.

TABLE 1

FAITH FUND UTILIZATION 2019-2021

2019

2020*

2021 March YTD

Number of people served

289

423

Number of loans provided

250

398

Amount borrowed

$753,505

$882,198

$208,327

Impact

$1,538,921

$2,208,920

$267,196 YTD

* Includes COVID-19 Faith Fund Emergency Loans

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multiple loans through The Faith Fund in the past and thought that was all we could do for her. She had several payday loans again and was embarrassed. But no need to fear, The Faith Fund is here! Because she had established a relationship with us and she had paid all her loans on time, we were able to consolidate all her loans. We paid off all her payday loans, her 401(k) loans and [money owed to] other third-party lenders. This increased her cash flow by over $994 monthly. She now looks forward to her paydays. She has money left over and has begun putting money into her savings account each payday. This team member calls The Faith Fund weekly to give her thanks. She said without someone so caring and willing to help, she does not know what she would have done or how she would have survived.” In the fall of 2020, The Faith Fund underwent another evolution with the opening of a lending center in North Baton Rouge. Through the Franciscan Ministry Fund, FMOLHS provided The Faith Fund with an unrestricted $50,000 annual grant to support the opening of a storefront on Plank Road, an area with multiple payday lending businesses. This brick-and-mortar presence extends the ministry to those most in need, brings community awareness to predatory lending and establishes an accessible solution in an at-risk community. As illustrated in Table 1 on the previous page, The Faith Fund has helped many. The initial $50,000 investment sits in reserve to pay off defaulted team member loans. The delinquency rate runs between 1.17% and 2%,

while the charge-off rate runs between 3% and 4.6%. (Charge-off rate is the percentage of a lender’s debt outstanding that is delinquent or bad debt.) During the pandemic, The Faith Fund saw delinquency rates rise as high as 12%, but this has since normalized to 5%. FMOLHS also committed to re-seeding The Faith Fund whenever the account balance falls below $35,000. This account is funded with unspent funds remaining in the Dependent Care and Medical Spending Accounts of employees. After an audit, the unspent funds are transferred to this team member assistance fund, allowing unused dollars to be used for employee support programs and resources. The Fund did not require additional funding until April 2021, when FMOLHS reinvested $23,468.80. The Faith Fund’s microloans have proven to be a wise investment, but the work is far from finished. FMOLHS is now incorporating proactive and preventative measures to the financial aid portfolio. For example, financial data indicates that team members often feel compelled to secure payday loans between pay periods. To counter this need, in January 2021, mission leaders across the system partnered with human resources to bring PayActiv to our portfolio of financial support services. Known as an earned wage access provider, PayActiv works with such companies as IBEX, Walmart, Amazon and Tesla, allowing employees to receive payment at the time work is completed, rather than at the end of the pay period.1 In its first four months, PayActiv has helped eliminate the need for predatory payday loans for nearly 500 team members (see Table 2). The ability to access earned income when needed, with-

TABLE 2

PAYACTIV UTILIZATION 2021

January February March April

Number of team members enrolled

210

421

474

488

Percent of population accessing funds

3.1%

3.4%

Average amount of funds accessed

$129

$140

$143

$142

Total amount accessed to date

$10,000

$82,000

$155,806

$230,949

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out having to ask for an advance, fosters dignity in work and respect for team members. FMOLHS plans to monitor use of PayActiv and The Faith Fund to determine whether these proactive investments enhance not only the team’s financial health, but also the fund’s overall sustainability. Our system mission calls us to be a healing and spiritual presence to each other as well as the communities we serve. Applied across a health system that employs more than 18,000 team members, these investments are significant. Team members are an extension of the healing ministry, and there is no greater asset than the return gained from investing in human capital. Suppose a brother or sister is without clothes and daily food. If one of you says to him, “Go, I wish you well; keep warm and well fed,” but does nothing about his physical needs, what good is it? In the same way, faith by itself, if it is not accompanied by action, is dead. (James 2:15-17, NIV) EMILY STEVENS is manager of social services at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana. COLETTA C. BARRETT is vice president of mission at Franciscan Missionaries of Our Lady Health System based in Baton Rouge.

NOTE 1. “Helping Low-Income Workers Stay Out of Debt,” Harvard Business Review, Nov. 2020, https://hbr.org/2020/11/ helping-low-income-workers-stay-outof-debt.

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Reflection

Feeling Boxed In, And Moving Beyond It ANN M. GARRIDO, DMin Associate Professor of Homiletics, Aquinas Institute of Theology

y cousin Liz and I chat by phone about her 10-year-old son Rique Ray’s recent drawing. “He calls it ‘The Death and Destruction of My Favorite Characters,’” she explains. We both look at the cartoonish figures, each in their own separate boxes getting squeezed into smaller and smaller spaces until colors—their true colors?—burst out. “Geez,” she says, “I hope these represent Disney characters and not, well …” We both laugh and seem to be thinking the same thing: “Not us.” Rique Ray lives with autism and expresses himself more easily through art than words so it is hard to garner what exactly he was thinking when he drew it, but we both agree it seems to capture what the pandemic experience has been like for our families. We’ve all been boxed in with the same people day after day after day. It feels like the rooms are getting smaller and our faces more scrunched. On the bad days, it feels like we are reduced to bulging eyeballs staring at one another. You again? Didn’t we talk about dishes left in the sink? About you not disturbing me when I’ve put a sign on the bedroom door? About turning the volume down on the TV while your dad is on a Zoom conference in the living room? I remember texting another relative, my sisterin-law, during the early days of COVID to see if I could set up a time to Zoom with my nephew. I was missing him and thought it’d be nice to just see his face some night that week. She immediately texted back, “Are you available now?” In between a thousand work emails, she had been trying for weeks to keep 5-year-old Ollie learning his alphabet and entertained with creative art projects, even online tours of the zoo. But, apparently, just before I texted, Ollie had the gumption to tell her,

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“You need to go to ‘Fun Mom School,’” and she’d lost it. When I reached Ollie on FaceTime, he was sitting with a blanket and his stuffed tiger inside a large cardboard box. “My mom says that this is a secret cave and that I need to hide in here until she finds me,” Ollie reported. We talked about tigers and how much he was missing his “wife,” 4-year-old Emma, next door. We talked about why moms sometimes yell even though they love you and why this nevertheless feels very unfair. After about a half-hour, his mom did come looking for him. It was OK now to get out of the box. It is a message that we are all slowly beginning to hear. With vaccinations we can see a wider range of possibilities for social interaction. And for some of us, that is hard also. One of my sister’s children hated attending high school online. The other one loved it and has no desire to return. The idea of “getting back to normal” isn’t always all that appealing, especially for those who were bored in the classroom even more than in the living room. Those who were bullied or suffered social anxiety. Those who were exhausted by the frantic pace of activity that used to be regular life. Who wants to go back to that? There are some redeeming aspects to life in a box, especially if

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you are able to have a blanket and a stuffed animal in there. All of which leads me to think back to a conversation I had several years ago while serving as the Sunday school catechist for a group of 9 to 12 year olds. We were reading the story of Noah and the Great Flood. We talked about the scene of death and destruction the Bible paints — not only people, but animals perishing under waves of water. It was a great puzzlement to the children and, again, seemed unfair to them that animals should be washed away when it was the humans who had sinned. When you read the story of the flood straight out of the book of Genesis, it really is a very sad story. Indeed, after finishing the last verse, we sat in silence for a while before the somber mystery of it all. And then one of the children said, “Well, you know, it’s different when the fish tell the story.” “Yeah,” another started to giggle, “When whale grandparents talk about the flood with their grandkids, they call it ‘The Golden Age of the Ocean.’” A number of others chimed in, “I bet they say, ‘It was the best time ever. It was when we ruled the world.’” I wonder in the future how our children will tell the story of this time? It definitely has been a season of death and destruction. And I imagine many will remember forever the tension and anxiety, anger and sadness that permeated daily family life. They will remember the absence of grandparents and cousins and their “wives” next door. They will remember graduations and proms and tournaments missed because they were stuck in a box. More grievously, there will be thousands upon thousands who remember being hungry. Some evicted from the “boxes” they once called home. Most tragically of all, more than 37,000 U.S. children will remember losing a parent to COVID, according to a recent JAMA Pediatrics analysis.

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And, without losing sight of the somber mystery of it all — not even for a moment — I imagine many will also remember it as a time of tenderness and genuine closeness. A time when they “ruled” what felt like their whole “world.” A time when for months on end, they had their parents all to themselves. A time when sibling bonds were cemented by hours and hours of running in circles around the same backyard in spring, summer, fall, winter, spring and now summer again. They will remember posting pictures of freshly baked pies on Instagram. Dusty Scrabble boards recovered from the basement. They will remember — but now with laughter — a time when their moms stuck them in boxes with blankets and stuffed friends. Neither version of the story will be truer than the other. Both will be Rique Ray Calvo true at the very same time, often within the very same family. Perhaps with time the many stories themselves will become squished together like the boxes in Rique Ray’s drawing. And maybe they’ll look back on the pandemic as a season in which the true colors of family life were squeezed out of us and we found out what we are really made of and who we really are to one another. And, yes, they’ll remember fiery red. There were definitely heated moments. But I hope they’ll also remember there was orange and yellow inside us. That there was orchid purple, cobalt blue and neon lime green. I pray they’ll look up at us, like Noah looking up at the sky years after the flood waters receded, and remember there was a rainbow. ANN GARRIDO is an associate professor of homiletics at Aquinas Institute of Theology and a regular preacher for the Dominican website The Word, word.op.org. She and her husband share one adult son, 13 siblings and 26 nieces and nephews.

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COVID Pulls Back The Curtain on Societal Plight ALEXANDER GARZA, MD COVID-19 Incident Commander – St. Louis Metropolitan Pandemic Task Force and SSM Health Chief Community Health Officer

“T

he most opportunistic biological weapon generally is what makes a pathogen also difficult to combat in the field. This includes easy dissemination, effective transmission, difficulty in detection and no vaccine or effective therapy. From a global perspective, if this is combined with an ineffective public health response, or a weak government, it becomes a catastrophe.” I wrote these words in Health Progress in the November–December 2019 issue, mere months before the most devastating pandemic the world has seen in 100 years erupted and spread across the globe. It is highly probable that while the magazine was being physically printed, the Severe Acute Respiratory Syndrome Coronavirus–2 (SARS-CoV-2), the virus that causes COVID-19 had already arrived in the United States; we just didn’t know it at the time. As I reflect on the article I wrote, titled “Guns, Germs and Health Care,” I am struck by how much of what was contained in those pages became reality. I have never wanted to be so wrong about something in all my life. In this previous piece, I wrote about my experiences with violence, firearm injuries and infectious diseases throughout my career as a paramedic and emergency physician, the Chief Medical Officer at the U.S. Department of Homeland Security and as an Army officer deployed to war. Over the past year I added another title, COVID-19 Incident Commander for SSM Health and then of the St. Louis Metropolitan Pandemic Task Force. Even though I had worked on the U.S. response

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to pandemics while at the Department of Homeland Security, mostly concerned with highly pathogenic avian influenza, I never fully comprehended the breadth and depth of the disaster that was to come. To be honest, I am not sure anyone could. It’s sort of like preparing to go to war for the first time. Your mind has no context to fully comprehend the experiences, the environment, the nuance, the sights, sounds and smells, the frustration, confusion and emotion that comes with it. With the pandemic, we encountered something like what we call in the military the “fog, friction and noise” of warfare. I know in Catholic health care we try to avoid the language of warfare to describe everyday occurrences, but I ask readers to make an exception in this case, both because of the scale of the pandemic and because much of my prior experience fighting disease comes from my service in the military and in national security. As I have reflected on this past year, the loss of life, the political and civil divisions in our society, the economic toll and the populations that were hit hardest by the pandemic, mostly the poor and vulnerable, it is difficult to recognize how life was

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prior to 2020. The past year has, at a minimum, amplified those things which make societies and civilizations fragile. I have chosen a couple of quotes from the original article to expand on through the lens of what occurred over the past year, and to offer some insight from parallel situations I have experienced since then. To begin, I’m returning to: “The most opportunistic biological weapon generally is what makes a pathogen also difficult to combat in the field. This includes easy dissemination, effective transmission, difficulty in detection and no vaccine or effective therapy. From a global perspective, if this is combined with an ineffective public health response, or a weak government, it becomes a catastrophe.” As a threat, the SARS-CoV-2 virus had all the hallmarks of a highly effective biological weapon. It was easily disseminated, using the host’s own respiratory system as an effective dispersal method. It made humans unwitting soldiers in its cause. It did not require anything to make it aerosolized, like what we had feared with highly milled anthrax while I was working at the Department of Homeland Security. The human lung machinery did this for it. This ability to travel in the air on tiny vapor bubbles created opportunity for the virus. As people gathered in enclosed spaces, it allowed the virus to create “mass effect” when either a highly contagious person or multiple people concentrated the virus in the air. This, coupled with the inherent viral capabilities and a completely unprotected host, made transmission easy, fulfilling the second requirement of an effective biological weapon. And of course, it was undetectable, especially early in the pandemic, when testing was limited or nonexistent. This allowed the virus to spread, initially undiscovered, throughout communities. It commandeered others to assist in its strategy by allowing persons to become infected and spread the disease while not even realizing their respiratory system had been co-opted. A clever feign by the virus. In addition, there was very little effective treatment other than oxygen and general supportive care for those who became significantly ill, and until December of last year, no vaccine. Having filled the requirements as an optimal biological weapon, it still required an ineffective

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public health response or a weak government to become a catastrophe. Despite the best efforts of infectious disease and public health experts, the fractured, political response to the pandemic was ineffective on multiple levels, leading to tremendous loss of life and untold suffering. “However scary a deliberate biological attack seems, nature is much more prolific at developing and spreading serious infectious disasters than any nefarious state actor.” A virus is one of the simplest things in the world; a strand of genetic material, in this case ribonucleic acid (RNA) surrounded by a protective protein coat, invisible to the naked eye and basic microscopy. There is still debate on whether a virus is a form of life. And yet, this strip of nucleic acids, properly organized, caused more death, destruction and economic damage than a world war. This virus resembled other “threats” to our national security, our economic vitality and our public’s health, only by means that were different from traditional actors, such as terrorist organizations. Had COVID-19 been a terrorist organization or a government that killed hundreds of thousands

As a threat, the SARS-CoV-2 virus had all the hallmarks of a highly effective biological weapon. of Americans, perhaps we would have seen a different response, something closer in scale to what the U.S. did after the attacks of 9/11, which directly resulted in two separate wars, costing trillions of dollars. Comparing what we have been through over the past year bears a striking resemblance to what I witnessed during war, however. The lack of appreciation for the lethality of the threat and the lack of recognizing a common enemy led to unneeded death and loss of livelihoods. One of the things that contributed to a poor response strategy was a failure to understand the fundamental strategy of the virus. Its sole strategy is quite simple: to replicate. A virus cannot reproduce on its own. It needs a host to make more of its kind, to survive, which then becomes

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the mission of its replicants. However, the virus, unlike human enemies, had no rational thought process, no ideology and, if war is political objectives by other means, it had no political objectives. This virus didn’t care about the legalities of mask wearing, the right number of people who can eat in a restaurant, or Emergency Use Authorizations, conservative or liberal, Black or white. It had a remarkable ability to manipulate politicians and others and drive a disinformation campaign without a single interview or organized media strategy. It leveraged existing divisions in the population and exploited them. It convinced leaders that it wasn’t such a bad thing, that it was like the flu or a bad cold; that it would be gone quickly, like an uninvited guest, and at its worst, that it didn’t even exist. It is therefore remarkable that one of the simplest forms in all of life, in all the world, with such a simple strategy, was able to bring such disruption to the highest life form. Combined with the disjointed health care system that is uniquely American, and the dismal neglect of public health over the decades, it created the perfect battlefield conditions on which to attack. And attack it did. In my article for Health Progress before the pandemic, I also wrote:

individual level and at a societal level – a result of conditions placed upon populations from prolonged neglect and discrimination. For instance, a well person, living alone or with just the immediate members of the family, with access to broadband internet, the ability to work from home and, therefore, with a steady income to pay for living expenses, has a much lower risk profile for multiple poor outcomes from the pandemic than someone born into poverty, who lives in dense, multigenerational housing, who must travel long distances on public transportation for a service

Combined with the disjointed health care system that is uniquely American, and the dismal neglect of public health over the decades, it created the perfect battleﬁeld conditions on which to attack. And attack it did.

“In many ways, however, infectious diseases are similar to gun violence. They affect the poor and vulnerable disproportionately and can span from small intense episodes, such as a case of meningitis or sepsis, to full-blown disasters, such as a the H1N1 pandemic or recent Ebola virus outbreaks.” Just as in warfare, the enemy will probe and exploit the weaknesses in defense. Similarly, those most at risk of suffering in war are the same populations that suffer disproportionately during the pandemic, mainly the poor and vulnerable. In epidemiology, the differences in disease outcomes are driven by risk. These can be described as the risk of becoming infected and once infected, the risk of a poor outcome. Risk, in life and in a pandemic, is not equally distributed across the population. Risk of contracting and having a poor outcome from COVID differs at the

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job that requires them to interact with multiple different people over the course of their day so they can make enough money to survive. From this, those who are least capable of protecting themselves are the ones who are most at risk and often bear the brunt of disease. Although COVID-19 has dominated our lives this past year, it certainly was not the only issue impacting society. The murder of George Floyd in Minneapolis, Minnesota, and the record-breaking year of homicides from firearm violence brought the country’s plights into full view. And so, it seemed rather prophetic that my previous article described the two dominating public health narratives over the past 16 months. In my previous article, I wrote of what we call in the military, the “boom” — the use of improvised explosive devices (IEDs). If you think of the efforts to prevent negative outcomes along a continuum, then “left of boom” were things that prevented an explosion, such as deterrence and detection, and “right of boom” were approaches after the fact, such as the response, tracking the perpetrator, care for those who had been harmed

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and more. In that article I wrote; “As Catholic health care providers, we must be both prepared to care for the victims and patients, but, just as important, our ministries also call us to work far left of the “boom” by mitigating negative influences and determinants for those our mission calls us to serve. It is through this approach that we can reduce the effects of guns and germs on societal success.” I am often asked, “What can we do to be better prepared for the next pandemic?” My answer is what you might expect: better disease surveillance, better vaccine manufacturing, etc. However, asking how to be better prepared for the next pandemic is the wrong question. The questions are how do we prevent the next disease pandemic, and how do we prevent more gun violence now. To this, we must work toward a more resilient community predicated on social justice. President Barack Obama once said, “When disaster strikes, it tears the curtain away from the festering prob-

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lems that we have beneath them.” The inequities, the “festering problems” that drove higher risk, morbidity and mortality for our communities, are not simply health problems; they are the issues that have great impacts on health, the “social determinants.” The pandemic and its aftereffects are not just the responsibility of those working in health care or public health: They belong to all of us. If we wish to prevent or minimize the probability of a disaster, or the everyday infectious disease or gun violence, or its second- and thirdorder effects, it requires unity of effort from the whole of society to work for a more equitable and resilient society. Working to eliminate poverty and discrimination and improve lives reduces the risk of disease for the whole—in pandemics, in gun violence and otherwise. DR. ALEXANDER GARZA is chief community health officer for St. Louis-based SSM Health and COVID-19 Incident Commander for the St. Louis Metropolitan Pandemic Task Force.

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ADVANCING PATIENT-CENTERED CARE

Bringing Social Support into the Fold ALISAHAH COLE, MD, and NICHOLAS STINE, MD CommonSpirit Health

he issue of social determinants of health has become a trending topic in health care, and rightly so. The Centers for Medicare and Medicaid Services has stated that achieving health equity and driving improvements for all patients require further investment in tools and approaches to address these determinants and close care gaps. Social factors — including housing, transportation, education and social isolation — affect communities of color in particular and negatively impact access to care and health outcomes. Even with increased focus on these socially driven health vulnerabilities, efforts to lessen inequities often reach only a fraction of the population — perhaps as few as 2% of all patients, according to CMS.1 At CommonSpirit, we’re committed to doing more and going further. Because we remain rooted in our foundational values of human dignity and social justice, we can put our energy toward determining how to best address social determinants of health, rather than convincing our staff why. It’s hard to overstate the impact that one’s economic stability, environment, relationships and access to resources has on physical health, and we’ve long recognized that the most effective care is comprehensive care, which extends beyond anthropometrics and biomarkers, such as blood pressure and weight. While our mission remains the same, CommonSpirit continues to evolve and refine our approach to deliver the most meaningful and impactful care. Our focus is on operationalizing equity, striking the delicate balance between large-scale standardization, local autonomy and

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tailored support. In other words, we can implement universal health screenings of social needs across our points of care and also recognize that different regions we serve have prioritized different social needs and therefore have varying levels of support for patients.

ADDRESSING INEQUITY ONE PATIENT AT A TIME

Meaningful social change often starts with personalized patient care inside our own health care systems, which requires understanding each patient’s unique social barriers and needs. From offering free language translation services at medical appointments to providing community resource referrals upon discharge from the emergency department, tailored social support is becoming ingrained. Our Total Health Roadmap model is guiding the way. Launched in 2017 with funding from the Robert Wood Johnson Foundation and the Catholic Health Initiatives Mission and Ministry Fund, the program is grounded in our commitment to create healthier communities and is focused on

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building a framework for successful scaling. The roadmap is driven by three core strategies: transforming our roles as providers, expanding our roles as community organizations and strengthening our leadership accountabilities. At the heart of the program are community health workers, serving as counselors, advocates and front-line links to community agencies and partners. We’ve embedded 15 community health workers in family medicine practices in select markets in Iowa, Colorado and Kentucky, ensuring they’re integrated into the care team and operating under the same roof as our clinical staff.

At the heart of the program are community health workers, serving as counselors, advocates and front-line links to community agencies and partners. We’ve also ensured community health worker support is accessible to all patients, regardless of insurance status. Every patient is offered the opportunity to participate in the social health screening process, though no one is obligated. Patients complete the screenings during their appointments, and community health workers meet with patients in need of assistance while in the clinic, if possible. They also follow up to determine if needs are being met and establish longterm relationships with many patients. Over the past three years, screening participation has increased with more than 40,000 screenings in our pilot clinics, a promising metric for a few reasons: we’re reaching more and more patients; screenings are becoming a trusted part of the care process; and physicians are providing additional prompts and encouragement to patients to complete the screening — a testament to how much they’ve come to appreciate the added value of the community health workers. And now we’re scaling this approach to additional communities. We still see a significant number of patients who complete the screening but ultimately decline assistance. This is consistent with what other orga-

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nizations have observed; their responses still give us important insights into the persistence of social needs in each area. While the Total Health Roadmap aims to serve as a model for our sites everywhere, relying on input from teams in the field and program champions at each center has been a major part of the program’s success. And as “warm handoffs” between providers and community health workers become more frequent, our patients are realizing their value, too. Lisa, whose name has been changed to protect privacy, is one of thousands of our patients whose lives have been touched by the community health workers. Lisa answered “yes” to every question on our screening form, indicating a high level of need. Although she was employed, she and her husband were living in a car with their 2-yearold and 5-month-old children. She indicated that they had been fishing for their food and that her husband struggled with alcohol abuse and posttraumatic stress disorder after his military service. A community health worker assisted Lisa, connecting her to other local organizations to secure permanent housing, benefits from the federal Supplemental Nutrition Assistance Program, and diapers and clothing for the children. They also helped Lisa’s husband find a local counselor who could assist with his PTSD and behavioral health struggles and obtained vouchers for gas so that Lisa could make it to work. These were crucial foundational blocks that Lisa needed to build toward a healthier life. And this is just one example of how our passionate, purpose-driven people are changing patients’ lives every day.

CLOSING THE CARE GAP WITH DIGITAL TOOLS

As an industry, we’ve long known that community-based, culturally responsive programs work, but we’ve lacked the capacity to deliver them in a cost-effective way and to scale them to serve thousands of patients. Today, a technology-enabled approach allows us to drive better outcomes for physicians, strengthen engagement and improve health in the communities that need the support the most. Digital tools such as virtual care, appbased screening and monitoring systems deepen our connections to some of our most at-risk and hard-to-reach patients. In 2020, CommonSpirit expanded our partnership with Docent Health, a health care technology company focused on personalized patient naviga-

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tion, to pair patients with non-clinical navigators who provide them with individualized guidance. Docent Health provides patient liaisons and a technology platform to help patients navigate their health care and to guide patients to the right resources. Docent Health’s platform centralizes patient information and creates tools like dashboards and scorecards to illustrate trends and care opportunities based on a health program’s goals. A pilot began in 2016, and more recently we’ve built off the program’s success with some maternity and orthopedic patient cohorts in particular. The pilot quantified how the platform’s innovative technology and navigator program have successfully improved patient health and utilization outcomes. The model also lowered the cost of care for maternity and orthopedic patients at the three pilot facilities, including vulnerable Medicaid patients. The pilot study included more than 10,000 of CommonSpirit’s patients and found new mothers had a 10% shorter average length of stay, Medicaid newborns with complications had a 1.8-day shorter length of stay, and preterm births for mothers on Medicaid fell by 37%. Orthopedic patients had a 45% shorter average length of stay, and 30-day readmission rates fell by 71%. The program will eventually expand to include more of CommonSpirit’s care sites across the country, while the virtual care navigators will improve continuity of care among the health system’s hospitals and extend to primary care practices, behavioral health specialists and community-based organizations. Ultimately, this support system allows us to scale services, which is especially critical for vulnerable and underserved populations.

INVESTING IN HEALTH BEYOND HOSPITAL WALLS

As an anchoring institution in the community, we have a responsibility to invest in our markets for lasting solutions that spark long-term change — a cure versus band-aid approach.

As an anchoring institution in the community, we have a responsibility to invest in our markets for lasting solutions that spark long-term change — a cure versus band-aid approach. CommonSpirit conducts needs assessments and creates implementation strategies every three years to identify and address significant health needs in the communities we serve, and we invest in the continuum of community-driven solutions to social determinants of health: housing, environment, job creation, arts and education, food and nutrition, and

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access to capital. These investments target key social determinants by funding efforts to develop resources in underserved neighborhoods, revitalizing urban and rural areas in need and empowering people in low-income communities through education, training and sustainable employment. Since the start of a community investment program in 1990, we’ve invested more than $277 million in community projects. Today, we have more than 100 projects with close to $107 million in outstanding loans. Without a safe space to live and a stable address, physical well-being is impossible. Therefore, nearly 45% of the current loan portfolio has been invested in housing, from establishing affordable housing projects and revitalizing low-income neighborhoods to addressing and preventing homelessness. Housing is also one of the largest financial strains on patients and a critical linchpin to other social determinants of health. CommonSpirit’s Homeless Health Initiative works to co-locate, coordinate and integrate health care, behavioral health, safety and wellness services with housing and other social services. Across California, for example, we have committed to investing at least $20 million through fiscal year 2024 to address housing insecurities and homelessness prevention for individuals and fam-

ilies, as well as to coordinate care and resources for people experiencing homelessness with local community partners and government agencies. Job creation is another critical need, and people in underserved communities often lack the space and the start-up capital to build their own business. At La Cocina, a nonprofit funded in part by CommonSpirit, women with culinary knowhow and a strong entrepreneurial spirit, but little financial capital or business experience, have access to a shared “incubator kitchen” where they

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can formalize and grow their own food businesses. Located in the ethnically diverse and economically vulnerable Mission District of San Francisco, La Cocina offers access to kitchen space as well as mentorship opportunities to create business and marketing plans. La Cocina has fostered the development of dozens of new small businesses and paved the way for a more inclusive and equitable food industry. Many of our community investments are made possible by our Social Innovation Partnership Grants program — funding allocated to up-andcoming technology companies and organizations with transformative approaches designed to increase access to resources and improve health outcomes. To secure grant funding, their solutions must be designed to meet the needs of low-income individuals with chronic physical or behavioral health conditions who lack access to coordinated services and health education. Among this group of innovative companies is One Degree, which has created a website and app that connect users nationwide with resources in their area to help them achieve economic and social mobility. From food assistance and affordable legal counsel to education opportunities and financial services, One Degree’s resources touch every domain of the social determinants of health. Since 2017, more than 500,000 people have accessed services through One Degree, using an estimated $20 million in resources they discovered through the platform.2 These initiatives have a ripple effect. Access begets access. Resources build self-efficacy. And strong social support enables healthier lives. Health happens everywhere, which means health care can no longer be confined to brick-andmortar hospitals and clinics. To effectively pro-

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mote health and well-being for all, the community must be a part of the care plan.

THE POWER OF PARTNERSHIP

No matter where the spark of social change starts, within our walls or out in our communities, one constant persists: the power of partnership. The meaningful impact we have on our patients’ lives is made possible by passionate advocates throughout our organization, the collaborative spirit of our care teams who have shared their input and insights and our local champions on the front lines who take ownership of this challenging work. Our deeply rooted connections to our communities prove invaluable. From forging joint efforts with other anchor institutions to fueling innovative social disruptors, our partners allow us to go further, together. As we fully realize the interconnectedness of human health — behavioral, social and spiritual — we must invest in interconnected solutions. ALISAHAH COLE is CommonSpirit Health vice president population health and innovation; NICHOLAS STINE is senior vice president population health. Contributors to this article are ELIZABETH EVANS, PhD, director, Total Health Roadmap and EDWARD SALVADOR, community investment program manager.

NOTES 1. For related information from CMS, https://www. cms.gov/newsroom/press-releases/cms-issues-newroadmap-states-address-social-determinants-healthimprove-outcomes-lower-costs. 2. More information about One Degree, https:// www.1degree.org/.

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A Formation Ecology for the Digital Age JARED H. BRYSON, DMin

Vice President, Mission and Church Relations, Mercy

n March 27, 2020, in a place where thousands usually gather to catch a glimpse and hear words of hope, the solitary figure of Pope Francis stood in St. Peter’s Square. Grappling with pandemic conditions, he offered prayer and supplications to God on behalf of humanity in an extraordinary blessing. Millions watched and joined in prayer, all virtually. This Urbi et Orbi prayer service reserved for the church’s most solemn occasions was moving, simple and straightforward. Yet, it stood in stark contrast to most papal liturgies that are full of pageantry and crowds of people gathering to celebrate. It was a defining moment for the future of the church and our faith experience. This shift to a virtual prayer gathering also signaled a shift in our experience of communal prayer and our relationships with one another. In Catholic health care facilities, we, too, have seen many defining moments during this pandemic. These have included staffing challenges, capacity spikes and changes to the ways we carry out formation, which has moved to rely more on virtual and digital platforms. We must recognize that life has changed in many ways, even as the vaccines continue to move us forward. If we only focus on “getting back to normal,” we will miss a significant opportunity. The COVID-19 pandemic has allowed us a different lens to examine our paradigms — some are calling it The Great Reset. We wonder about

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the pandemic’s long-term effect on the ministry. The last year has provided challenges, dialogue and opportunities for innovation in how the people of Catholic health care experience ministry formation. While the possibility to examine our established ways of doing things existed before the pandemic, COVID accelerated the timeline. It has uncovered further questions, new audiences and new longing to connect meaningfully with one another. It calls for us to rethink formation’s role in mission integration, ministry identity and leadership development to move intentionally beyond gathered programming to an ecological approach to formation. Formation, which is personal, professional and organizational, is not a particular program or event. It is a person’s journey with meaning, purpose, and spiritual and material matters in dialogue with the organizational story. The pandemic heightened the need to shift from specific educational formation programs to a formation ecology — the overall and incarnational experience of the ministry, to embody the ministry through our presence and in acting as Jesus would act.

MOVE FROM FORMATION PROGRAMS TO FORMATION ECOLOGY

A formation ecology recognizes all the elements of our ministry — employment practices, organizational practices, spiritual practices, ways of communicating, artwork in our facilities and

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more — are part of individual and organizational spiritual growth, enhanced meaning and purpose in our work. When we change one element in formation, it affects other aspects of the formation ecology. In Catholic ministry, we experience three different phases of ministry engagement. Ministry engagement begins with the incarnational experience in the one-to-one, face-to-face encounter with another person. Human nature draws us toward personal interaction and sharing stories about the common institutional story, such as our practical day-to-day realities, prayer routines, spiritual practices, moments of connection or environmental surroundings. Integral to this experience are strong Catholic identity, leadership, clear communication channels, operational clarity, transparency and encounters with others. We then move from our most ideal incarnate state to an intermediate state. The intermediate state focuses on other aspects of the environment, such as art, culture, digital and virtual resources. These additional tools enhance the formation process, leading to reimagined personal encounters with patients and families, as well as with coworkers. Beyond the intermediate state, there is an utterly “discarnate” state, to borrow a term from Marshall McLuhan. This occurs when we are present through means like our voice or our image, but not physically occupying the space. The work of McLuhan, a convert to Catholicism and a Canadian philosopher, is integral to media studies. When we explore meaningful virtual formation, it’s helpful to explore the context of the disembodiment of an embodied ministry. When we put all these levels together, we can see there is a formation ecology that can move us to greater mission integration. However, this still leaves us thinking about formation and its “end goals.” How do we address paradigms regarding the human person, communication, community, culture, and the person’s formation process or formation ecology of our ministry?

tion to connection, community and communion through social communication tools. These days, such tools include everything from phones to teleconferencing to social media platforms. When strategizing about approaches to online formation, it makes sense to embrace a “digitalfirst” strategy. That’s because thinking first of the virtual or digital experience requires us to intentionally create new experiences that lead to personal and incarnational encounters. They won’t

The rapid development of virtual and digital formation forced us to explore our overall formation ecology and look at current formational biases, processes and programs.

MOVE FROM COMMUNICATION TO CONNECTION, COMMUNITY AND COMMUNION

In the 1971 pastoral instruction Communio et Progressio, we are called to move from communica-

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be fully successful if we treat online formation as merely a supplement to in-person experiences. We have to rethink virtual offerings to make them more meaningful. For instance, one benefit of electronic communication is that it has allowed us to quickly connect groups and individuals across the health ministry, to hear and understand stories of patients and employees. Such communication can help us identify needs — material, spiritual and emotional — and provide resources to under-resourced communities. The rapid development of virtual and digital formation forced us to explore our overall formation ecology and look at current formational biases, processes and programs. For effective electronic formation, we are rethinking a great deal, including the need for better visuals. We’re addressing when it’s more effective not to have visuals, when to have a call without information on slides. We’re also giving more thought to group size, when it makes sense to have a lot of people on a call and when we should be more intentional about small groups. In the current moment, digital communication and content might lead us to believe that the purpose of communication is just the transmission of information. But communication is about so much more — building connections, community and ultimately communion among people. In a time of pandemic, building a community needs

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other avenues when coming together in person isn’t possible. This is also true when we are trying to bring together a health ministry located in very different geographies. We must hold in tension that community exists in both a virtual context and a face-to-face context.

DIGITAL AND VIRTUAL FORMATION: A DILEMMA

When we address formation via digital and virtual structures, we often focus on the content, which is a valid focus. However, the “formation ecology” also should be a significant focus. Ministry formation is a discipline of study and integral to mission integration. It is a discipline with its own processes and methodologies that integrates “what” we do with the “why” of Catholic health care’s mission. One of the methodologies of ministry formation is the importance of formation being in dialogue with another discipline. Ministry formation in Catholic health care can be in dialogue with the methodology of delivery, in this case, the delivery of communication. As McLuhan says, “The medium is the message.” He points out that the content is shaped by the medium that is used to deliver the message. McLuhan is interested in the formal cause of the medium and not the efficient cause. In the case of digital and virtual formation, I believe we should be doing the same thing. As a reminder, the material cause is the beginning of a thing, as wood is for a table. A formal cause is related to the design of the wood being changed to eventually become a table. We need to sufficiently explore the formal cause of digital and virtual environments, how to shape the experience for meaningful and worthwhile outcomes. While many issues should be addressed when moving to digital and virtual formation, let’s focus on the use of videoconferencing technology, to gather people for formation group meetings that have historically been face to face. The McLuhan tetrad is a way of understanding some of the effects of media on a particular environment. Each tetrad answers the following four questions: Enhances: What does the medium improve?

Retrieves: What original idea or ground is being brought back by the medium? Reverses: What happens when the medium is pushed to its limits? Obsolesces: What does the medium make obsolete? We can say that videoconferencing — such as Zoom or Webex calls — can enhance a sense of group feeling. Video calls allow the group to remain connected. However, when pushed to their limits, these group calls become another part of the “noise” overload, failing to connect and instead fueling isolation in people. This is true with much larger video conference calls. The virtual tools can retrieve or call to mind a Campfire Prayer Service. At a Campfire Prayer Service, a small group sits around a glowing light sharing stories and spiritual beliefs. In using these tools, what is made obsolete or unnecessary is the particularity of place, namely the office. When we communicate virtually, there can be a mixing of intention. The computers or phones

When we communicate virtually, there can be a mixing of intention. The computers or phones used for formation are the same devices used to accomplish work responsibilities and/or to check in on other online distractions.

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used for formation are the same devices used to accomplish work responsibilities and/or to check in on other online distractions, like Facebook, Twitter, etc. Online engagement with digital technology is part of the attention economy that favors division and individualism. The online environment is a shift in thinking and presence, from focused attention to multitasking. There’s a shift from a quiet medium of face-to-face communication to a noisy medium, from the warmth of human interaction to a cool blue glow of the screen. The online tools and environment can shift the ways in which participants in a formation encounter experience it, and its receptivity. The discarnate communication over teleconferenc-

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As we were developing our online approach, the team was obliged to revisit our formation paradigms to better understand our proposed outcomes and how to meet them. ing links, where we are not physically gathered together, calls into question the dilemma around the incarnational reality of the ministry we are charged with bringing to life. The medium, by its very nature, modifies the content. How will this discarnate reality of digital/virtual formation affect an incarnate ministry’s culture? How can a discarnate means enable new incarnate connections, community and communion? In his Apostolic Letter The Rapid Development, St. Pope John Paul II, while praising the use of various forms of digital communications media for formation and evangelization, reminds us of the cultural implications. We are dealing with a complex problem, because the culture itself, prescinding from its content, arises from the very existence of new ways to communicate with hitherto unknown techniques and vocabulary. (3) The new vocabulary they introduce into society modifies both learning processes and the quality of human relations, so that, without proper formation, these media run the risk of manipulating and heavily conditioning, rather than serving people. (11)

THE MOVE TO DIGITAL AND VIRTUAL FORMATION

Early on in the COVID-19 pandemic it became clear that we could not carry out our traditional face-to-face gatherings for formation. Further formation programs were put on hold for revamping or reenvisioning while we developed the virtual and digital formation programs to meet the current needs. At St. Louis-based Mercy, a group of mission and formation leaders began researching and collaborating, moving our formation efforts quickly to a digital and virtual space. As we were

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developing our online approach, the team was obliged to revisit our formation paradigms to better understand our proposed outcomes and how to meet them. Early on, each health care leader involved in the process seemed to have his or her own notion of what was needed to move online successfully. Ideas fell into three general categories derived from Heidi Campbell’s article for the University of Notre Dame’s Keough School of Global Affairs, “Distancing Religion Online: Lessons from the Pandemic Prompted Religious Moves Online.” They are: Transfer — we attempt to replicate what we do in person and put it online. Translation — we adapt some aspects of our formation efforts to respond to the constraints of virtual only, creating challenges in building community and engagement. Transformation — we embrace what technology could facilitate to build community, “true connectivity over feelings of isolation,” meeting the needs of our coworkers and leaders, engaging with them in practical ways. Each of these three categories presented a moment to revisit our paradigm and our usual patterns. We continue to explore how to best do formation work virtually. For instance, one outcome for new leader formation is to “define what is expected of Mercy leaders to sustain the Mercy mission and health care ministry including the role of mission as a partner.” This one outcome became more specifically defined by the nature of the medium and in looking for new ways to engage the whole person. It was then made into eight new outcomes, several that included intentional opportunities to meet with someone locally. These changes solidify a commitment to revisit our formation paradigm regularly.

MOVING FROM FORMATION PROGRAMS TO FORMATION ECOLOGY

Borrowing from environmental studies and Pope Benedict XVI’s image in his 46th World Communications Day letter, Silence and Word: Path of Evangelization, he invites us to consider the impact of what I am calling the “formation ecology” for Mercy’s health ministries. When messages and information are plentiful, silence becomes essential if we are to distinguish what is important from what

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is insignificant or secondary. Deeper reflection helps us to discover the links between events that at first sight seem unconnected, to make evaluations, to analyze messages: this makes it possible to share thoughtful relevant opinions, giving rise to an authentic body of shared knowledge. For this to happen, it is necessary to develop an appropriate environment, a kind of ‘eco-system’ that maintains a just equilibrium between silence, words, images and sounds.

AS WE ADVANCE

The COVID-19 pandemic has challenged and changed the formation ecology, and there is no going back. There is no return to a pre-COVID formation strategy because our new experience has shown us a way forward to integrate in new and innovative ways. The digital-first method for formation is just beginning to evolve. Now is not the time to pine for the old normal but to continue innovating and moving to a more in-depth dialogue. What are we learning from the present moment? What do we do next? How are we deepening our connections within the various ministries within our health

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system and building stronger communities and, ultimately, communion? How do we transmit an incarnational ministry tradition in a discarnate reality, where we engage with people through virtual and digital means? Does the medium we are using provide “counter formation” to the content we are trying to instill in our communities? How are these tools continuing to shape us and our cultures? How are we being made in the image of technology and its ends versus the image of God and the ends of humanity? What new rituals and practices and/or the rediscovery of older ones support a shift in a formation ecology? Many learnings are coming from this time of innovation. Instead of focusing on “getting back to normal,” now is a time to enter into dialogue and create a formation ecology that defines our ministry’s future. This is not the work of mission and formation leaders alone; this is the work of all of us responsible for continuing to bring to life the healing ministry of Jesus. JARED H. BRYSON is vice president, mission and church relations, Mercy.

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MISSION

COVID, COMMUNITY AND CATHOLIC IDENTITY

he environment we live in and the people we live with can impact our overall health. So, as we continue to live through the coronavirus pandemic, it is important to ask how COVID-19 has affected families.

A quick internet search on the topic “COVID-19 and impact on families” yields hundreds of articles. The vast majority point to the negative impacts: additional stress for parents, especially mothers; physical separation from older relatives; unemployment; economic hardBRIAN P. ship on low-income families, SMITH who have no access to the internet for their children’s remote learning; the psychological welfare of children; teens unable to socialize with their friends. The list goes on. A few point to positive impacts. Some families have spent more time together, eaten more homecooked meals, played board games together and engaged in deeper conversations on important family decisions. Households not financially impacted by COVID and parents able to work from home seem more likely to recognize some of the bright spots. Health care providers have experienced these same struggles in their own families. In addition, they have been in the midst of the coronavirus, either on the front line caring for patients or in supportive roles to patients and caregivers. I would like to broaden the subject of COVID’s effect on families to include its impact on the people we may spend as much time with as the people in our home — our workplace family. For those of us who serve in Catholic health care, we see our colleagues not simply as fellow workers but as members of a community of healing and compassion. Obviously, there are distinctions between our home and workplace families, including a healthy respect for needed human resources policies and professionalism. Yet, it is important to ask about the social impact COVID has had on our workplace relationships. How has

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the pandemic impacted our workplace environment? How has COVID affected the people who work within our facilities and those working remotely? What are the lessons we have learned, and what are the challenges this pandemic has created when it comes to remaining a community and maintaining our ministerial identity?

COVID’S IMPACT ON THE WORKPLACE

The impact of COVID on Catholic health care is still unfolding. Over the last 18 months, CHA has talked with sponsors, chief executive officers, chief financial officers, clinicians, mission leaders, ethicists, chaplains, human resource and organizational development leaders, formation leaders and others to learn what their organizations are experiencing and to identify the common challenges we need to solve collectively. In early 2020, the issues that emerged around the coronavirus included personal protective equipment; ethical protocols for the allocation of scarce resources, such as ventilators and ICU beds; protocols for spiritual care for patients with COVID; the loss of revenue from cancelled surgeries; and the furloughing and dismissal of some personnel. By April 2020, we began to realize that the coronavirus was shedding a new light on an old problem — health disparities. The virus has disproportionately affected communities of color, people living in poverty and the elderly. People in these demographics were more likely to become infected by the virus, more likely to be hospitalized and more likely to die from COVID. Though not related to COVID, the killing of George Floyd on May 25, 2020, and the nationwide protests calling for criminal justice reform and an end to racism impacted Catholic health care as well. The CHA Board of Trustees had been ready to approve the 2021-2023 strategic plan but decided to hit pause and incorporate a new strategic priority: “Promote a culture of human dignity that

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serves as a foundation for eliminating racial dis- change is in the large number of administrative parities through improved health and confronting and shared services personnel working remotely racism.”1 Since the strategic plan was approved, from home. Many systems learned that not only CHA and its members have embarked on a jour- could the work be done, but in some cases, deney named We Are Called: Confronting Racism to partment productivity actually increased. Some Achieve Health Equity.2 As of early May, 83% of systems have decided to continue to have some CHA members had signed a pledge to work col- employees work remotely and reduce their real estate footprint. This not only will reduce such lectively to address this social injustice. As the second and third waves of the pandemic expenses as rent, utilities and maintenance but is swept our nation in the summer and fall of 2020, popular among many employees. But what will happen to our culture and Cathowe heard of the emerging concern over caregiver fatigue. The long-term effects of the pandemic on lic identity as we transition to a model in which direct caregivers are causing burnout, compas- thousands of employees work from home, while sion fatigue, moral distress and post-traumatic colleagues who serve in direct patient care still stress disorder. In May 2020, CHA and its mem- work within the facilities? How will this impact bers formed a Well-Being Task Force to see what systems could What will happen to our culture and learn from each other about wellCatholic identity as we transition being for care providers and to promote effective tools and resources.3 to a model in which thousands of As work on a safe and effective vaccine for the coronavirus employees work from home, while progressed, CHA helped promote colleagues who serve in direct patient ethical guidelines for equitable distribution of the vaccine and clear care still work within the facilities? guidance on the moral permissibility of vaccines that have been approved for emergency use authorization.4 In ad- our ability to be a community of healing and dition, CHA has joined other Catholic ministries compassion? Is it possible to form community in an education and communication campaign to virtually? Will staff who work remotely forge the same kinds of relationships with clinical staff ? address vaccine hesitancy. Each of these areas has created new challenges What creativity and energy is lost when people and opportunities for our ministry. Like the issues across departments do not see each other except COVID raised for families, some of the challeng- through a virtual meeting platform? Can prayeres of the pandemic have created new stressors in ful discernment around major decisions occur if a the health care arena. Some of these challenges, unified community has not been formed? however, have been answered with great creativity, resulting in positive change. Among them is ESSENTIAL ELEMENTS OF CULTURE the commitment to care provider well-being, not During this chaotic period of transition, I have only during the pandemic, but moving forward. referred to one of my favorite presentation modCOVID forced us to better address this issue, and ules, Stewarding Organizational Culture in the we can never stop caring for those who care for Catholic Tradition. During the presentation, I ask our patients and residents. participants, “What makes up culture?” The discussion always leads to a rich exchange of ideas. THE IMPACT ON COMMUNITY AND MINISTRY IDENTITY Culture is first about people who come together I also would like to focus on how COVID has around a shared set of beliefs and values. Because changed the way people within Catholic health of these shared values, the people who make up care relate to one another. From conversations the culture have clear expectations and expected with sponsors, CEOs, system mission leaders and ways of behaving that demonstrate a committhose who lead ministry formation, we’ve learned ment to those values. In Catholic health care, our that the dynamic in how we come together as a shared beliefs and values are the healing stories of community has changed. The most dramatic Jesus, Catholic social teaching and the other rich

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traditions of Catholic theology, ethics and spirituality. The way we deliver care to our patients, residents and community is the way we live out our commitment to these shared values. Rev. Gerald A. Arbuckle, SM, writes in his book, Catholic Identity or Identities?: Refounding Ministries in Chaotic Times, that leaders are “culture bearers” who must steward the desired organizational culture, especially during chaotic times.5 He recommends five practices for culture bearers. First, leaders must know and tell the foundational stories, namely the healing stories of Jesus and how the religious congregations who began our health ministry in the United States were inspired by the gospel and unselfishly answered the call to serve the unmet needs of people. Second, leaders must demonstrate the core values of the organization and lead by example. Third, leaders must stay grounded in the tradition, participating in educational and formation programs and applying those lessons to the areas they oversee. Fourth, leaders build and maintain culture through the use of symbols and ritual. During COVID, members have tried to be creative in how they pray, bless and celebrate key moments in the organization, such as the commissioning of new hires, Founder’s Day, and blessing nurses and other care providers during Health Care Workers Week. But many also report challenges from the inability to gather as a large group because of social distancing guidelines, the loss of rituals that involve anointing or blessing of hands and the absence of prominent, meaningful symbols for people working remotely. We cannot underestimate the power that rituals and symbols have in building bonds of community. When the community cannot gather in one place and instead is in multiple places, the bond of community is not the same. Those of us who attended Mass or other church services online during the pandemic know how our hearts ached and yearned for a return to gathering in person and experiencing the fullness of communal worship. Many members report that same type of longing among staff. We must be careful that after COVID we retain times when we can gather as community and celebrate. Finally, leaders must assess the culture regularly and hold the organization accountable. In Catholic health care, ongoing ministry identity

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assessment is the primary way we assess if we are living the core values that we profess are essential to Catholic identity. Related to ministry identity assessment is the ongoing formation we offer to leaders so they know what is expected of them, helping them to grow personally so they can lead the organization’s culture.

CONCLUSION

Just as we have seen the impact COVID has had on families, we need to recognize its impact on our workplace family. Some of the challenges brought on by the pandemic have caused additional stress, while some have resulted in innovation. It is important for leaders in Catholic health care to remember the essential elements of culture during and after the pandemic. Undoubtedly, the health care environment will continue to change, and we will need to adapt. The way we deliver formation may also evolve, and how we come together as community may need to adapt. But it is important for us who are “culture bearers” to remember that our identity and culture do not change. Striking this delicate balance of what is foundational and what is adaptable is an emerging opportunity for leaders in the post-COVID era. BRIAN P. SMITH is vice president of sponsorship and mission services, the Catholic Health Association, St. Louis.

NOTES 1. “The Catholic Health Association 2021-2023 Strategic Plan,” https://www.chausa.org/docs/default-source/ default-document-library/cha-2021-2023-strategicplan-framework.pdf?sfvrsn=0. 2. “We Are Called Overview,” Catholic Health Association, https://www.chausa.org/we-are-called/overview. 3. Dennis Gonzales and Carrie Meyer McGrath, “CHA Offers Resources on Care Provider Well-Being,” Health Progress, 102, no. 2 (Spring 2021): 78-79. 4. “Vaccine Equity and Principles for the Common Good,” Catholic Health Association, https://www.chausa.org/ newsroom/news-releases/2020/07/27/vaccine-equityand-catholic-principles-for-the-common-good. 5. Gerald A. Arbuckle, SM, Catholic Identity or Identities?: Refounding Ministries in Chaotic Times (Collegeville, MN: Liturgical Press, 2013).

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H E A LT H E Q U I T Y

RESPONSIBILITY ETHICS IN THE AGE OF CORONAVIRUS Considering Health Care Access for Undocumented Immigrants AIMEE ALLISON HEIN, PhD

or many, the vaccination sites that have popped up across the country have provided a reason for hope, an indication that the COVID-19 pandemic may be nearing its end. For some immigrant families, however, vaccine distribution has been a source of stress and fear. People without legal immigration status hoping to get vaccinated face a number of potential hurdles. In part, these barriers stem from systematic exclusion predating the pandemic. Under the Affordable Care Act, undocumented immigrants are not eligible to purchase insurance in the exchange or for subsidies to purchase health insurance. In addition, they are largely excluded from other federal health programs such as Medicaid. Moreover, while the federal government has insisted that everyone, regardless of immigration status, has the right to be vaccinated, the reality is not that simple.1 Some sites require documentation to facilitate reimbursement from the government for the cost of the vaccine.2 There are also reports of employees at pharmacies and campus distribution sites asking for proof of residency or insurance to be vaccinated.3,4 While such cases appear to be isolated failures to follow established policies, these stories do nothing to bolster undocumented immigrants’ trust in health care systems and their fears of discrimination.5 Given the highly contagious and indiscriminate nature of the coronavirus, these barriers that keep undocumented immigrants unvaccinated put not only their individual health at risk, but also the health of their families and the broader public. From the perspective of Christian ethics, these practices and their consequences are at odds with the belief in our deep interconnectedness and all the ways we are in relationship with one another. For Catholic theologian Charles Curran, relationships are a central theme in scripture and the Catholic tradition. His “relationality-responsibility model” of ethics aims to similarly center relationships, viewing the concrete details of specific

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relationships as important data for guiding moral action.6 People, he argues, live and make decisions within networks of relationality. Acting rightly involves responding well to the demands of these relationships.7 Such a framework proves consistent with the values of Catholic social teaching by seeking to balance concern for the individual with attention to the demands of the common good. Responsibility ethics, then, is a framework in which acting ethically requires a consideration of our relationships and how we respond fittingly or unfittingly to those relationships. Applied to immigration, a responsibility ethics approach considers how we have been and currently are in relationship with each other, as citizens and migrants, and how those relationships come with responsibilities and obligations that might guide our moral decision-making. In health care, a responsibility ethics framework directs us to four crucial considerations. First, the coronavirus pandemic makes clear that everyone needs access to quality health care. Now more than ever, we see that health care cannot be tied to income or documentation status alone. Health care is an important element of the common good in that it contributes to the conditions that allow people to flourish. On a pragmatic note, our health is directly dependent on the health of the people around us. We have a responsibility to contribute to the common good and to be in just relationships with our communities by doing all we can to avoid contracting or spreading

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the virus. Because our ability to stay healthy is so people who are undocumented aren’t afraid to deeply interconnected, as a society we each have access health care and other vital social servica responsibility to ensure that all people have ac- es. Along with new policies to expand access to cess to health care that can allow them to limit health care and health insurance, this will require the virus’ spread. Responsibility to the specific dismantling policies that discourage people who relationships in which we find ourselves, wherein are undocumented from accessing essential sereach of us depends on others to maintain good vices. Further, building trust requires tangible efhealth, demands that we provide each other ac- forts to establish accountability.10 Undocumented cess to the means to maintain good health. immigrants need real reasons to believe they will Second, according to the Center for Migration be treated differently than they have been in the Studies, 74% of undocumented workers are con- past. sidered “essential infrastructure workers,” which Establishing trust and accountability can inis nearly 10% more than the native-born labor clude a number of different concrete actions. force.8 In other words, undocumented workers Because public health intersects with a network make up a disproportionate percentage of the es- of other social, political and economic concerns, sential workforce that has been on the front lines successful vaccine distribution must work with of this pandemic, providing sanitation, food and the delivery of goods. Responsibility to the specific Despite this, the barriers that limit access to health care, including vacrelationships in which we find cines, persist for undocumented imourselves, wherein each of us migrants. By failing to adequately address these barriers while continuing depends on others to maintain good to rely on undocumented labor, we health, demands that we provide fail to be in a relationship grounded in mutuality. It is unjust to continue each other access to the means to to rely on them to put themselves at risk while denying them access to maintain good health. vital health care services, even if the denial of access is unintentional. We have built a society that depends on the labor of other policy efforts.11 While the Department of undocumented immigrants. They have a right to Homeland Security has promised not to “conexpect access to basic needs, such as health care, duct enforcement operations at or near vaccine in return. To deny them access is a failure to re- distribution sites or clinics,”12 there is little in spond justly to them as community members with terms of tangible law or policy holding the agenwhom we are in relationship and on whom we de- cy accountable, and immigration agents have a pend. documented history of staking out health care faThird, given that undocumented immigrants cilities.13 Ideally, public health efforts of vaccine are so embedded in our communities and the distribution would be paired with new policies ways that we rely on them, we must also consider that prevent undocumented immigrants from reasons they might be hesitant to access health being detained or deported. Health care systems care services. For example, staffing vaccine dis- ought to consider how they might ensure immitribution sites with uniformed members of the grants’ safety. In states like California, Illinois National Guard, while efficient, might dissuade and Maryland, partnerships with churches and immigrant families from getting vaccinated.9 One other trusted community organizations provide of the most difficult hurdles to overcome in pro- immigrants with information and hold vaccinaviding health care to undocumented immigrants tion events. Doing so diminishes the fear some is the distrust many immigrants have for U.S. sys- might feel by allowing them to access care at a tems. Undocumented immigrants who fear being more comfortable location.14 reported and deported are less likely to seek out Structural sin refers to the ways in which our medical care when they need it. Taking respon- social structures and institutions create an unjust sibility, therefore, includes considering how to distribution of resources and power, contributing repair this situation and establish trust so that to a situation of sinfulness that goes beyond any

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one person’s choices or actions. The barriers that keep undocumented immigrants from accessing health care are an example of structural sin. As such, the proper response is conversion — not conversion to a particular religious worldview, but rather conversion to a more just way of living together in society. Mark Kuczewski, a philosopher and bioethicist at Loyola University, highlights the importance of conversion “away from a status quo that settles for unjust immigration policies,” and toward a full recognition of people who are undocumented as members of our communities.15 While he is specifically responding to institutional barriers that prevent undocumented young people from access to education and jobs, his call to a conversion of our existing relationships with undocumented immigrants is more broadly applicable, and fits well into the responsibility framework of health care. The disproportionate number of undocumented workers who

take on the essential jobs that Americans have relied upon during this pandemic brings into sharp focus the ways we depend on undocumented immigrants and how they are already deeply embedded in our communities. Responsibility ethics calls us to consider how we can make this relationship more just. Forming more just relationships with the undocumented immigrants so often excluded from equitable access to health care requires the creation of structures of solidarity and tangible support. Churches and other community groups that build relationships with undocumented immigrants can help assuage immigrant’s fears and protect their safety. (See sidebar.) These actions could include accompanying undocumented immigrants to vaccine appointments, locating “safe” health care professionals they can direct immigrants to, establishing safe sites for vaccine distribution, or offering supports when someone is

WHAT’S WORKING?

n Baltimore, the Sacred Heart of Jesus Parish provided vaccines to undocumented immigrants who live nearby. By providing a convenient location and by virtue of the trust the parish had established with the community, they assuaged fears.1 Churches in Chicago, Maryland and California scheduled appointments for immigrants, a simple way to make the vaccination process less intimidating. Both California and Maryland partnered with churches and other trusted community organizations to host small vaccination events.2 In Kingston, New York, La 2nda Iglesia La Misión provided vaccines at its building. Beforehand, the pastor partnered with the county sheriff, Juan Figeroa, to provide information and quell fears. The sheriff is a trusted voice in the community because of his public support for pro-immigration policies and because he is Hispanic and speaks Spanish. Members of the community report that his assurances of their safety and the information he provided had a direct impact on their comfort level.3 In Boston, Stop the Spread testing sites have provided free, no-questions-asked COVID-19 tests that helped increase the number of undocumented immigrants tested. Immigrant activists suggest that a similar program for vaccine distribution will help undocumented immigrants access the vaccine.4

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These examples all required building relationships with immigrant communities. Historically, the most effective efforts to provide immigrants with essential services occur when churches and other community organizations build relationships with immigrant communities and partner with known and trusted nonprofits. NOTES 1. Tim Henderson, “Churches, Community Groups Help States Vaccinate Immigrants,” Pew Trust Stateline, March 9, 2021, https://www.pewtrusts.org/en/ research-and-analysis/blogs/stateline/2021/03/09/ churches-community-groups-help-states-vaccinateimmigrants. 2. Henderson, “Churches, Community Groups Help States Vaccinate Immigrants.” 3. Ben Nandy, “Sheriff Seeks Immigrants’ Trust as He Promotes COVID-19 Vaccine,” Spectrum News, March 23, 2021, https://spectrumlocalnews.com/nys/ hudson-valley/news/2021/03/23/sheriff-encouragesimmigrant-families-to-get-the-vaccine-. 4. Tori Bedford, “Fear of Deportation Prompts Undocumented Immigrants to Resist COVID-19 Vaccine,” WGBH, January 7, 2021, https://www.wgbh. org/news/local-news/2021/01/05/fear-of- deportation-prompts-undocumented-immigrantsto-resist-covid-19-vaccine.

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reported or detained after receiving the vaccine. and healthy, we have a responsibility to repair the They can secure legal aid, participate in protests, relationship and, at the very least, provide more or provide sanctuary in appropriate church or sufficient health care and safer policies in detencommunity buildings. Not only will this improve tion centers, including prioritizing vaccines for the health of undocumented immigrants and con- detainees. A responsibility ethics framework tribute to overall public health, but it can lead to holds that ICE does, in fact, have a moral responmore widespread societal conversion away from sibility to ensure those in its detention centers structures of sin and toward the values of the have access to vaccines. Moreover, the federal common good. Kuczewski reports that creating government and state health departments have structures of solidarity has led other organiza- responsibilities to be clear in their communications to hear the “prophetic cry for justice” and tions to ensure that detainees do not fall through begin their own efforts to create a more just situ- the cracks. As long as we, as a society, continue ation.16 Churches and other Christian organizations can show the world A responsibility ethics framework what is possible and call publicly for necessitates we pay attention to the reshaping of the United States into a more just society. how unjust relationships can be Finally, we need to consider migrants held in detention centers. repaired by creating accountability These facilities are known for keeping and taking concrete responsibility people in close quarters, inadequate mask distribution, failure to report for past injustices. infections, expecting employees to work when sick and frequent transfer of detainees between facilities that adds to the to use detention as a centerpiece of our immigrapossibility of contagion and infection.17 They are tion policy, we must take more responsibility for hotbeds for the virus, with more than 10,000 cases the health and safety of those we detain and the reported,18 a significantly higher rate of infection impact detention has on public health. Responsibility ethics offers a helpful framethan is seen within the broader U.S. population. Detainees have also reportedly received incon- work not only for diagnosing the problems facsistent access to health care when sick. In short, ing undocumented immigrants as they navigate some U.S. policy has directly threatened undocu- the U.S. health care system, but also provides a mented migrants and public health.19 Moreover, path forward for those of us invested in creating Immigration and Customs Enforcement (ICE) a more just future. Justice will require better rehas no vaccination program of its own, unlike its lationships, and better relationships start on the counterpart, the Federal Bureau of Prisons. ICE ground, person to person and community to cominstead chooses to deflect responsibility to the munity. In conclusion, I offer a set of questions health departments of state and local govern- churches, community groups and Catholic health ments.20 Yet some state health departments have care services can ask themselves as they consider stated that they won’t vaccinate people in ICE what steps they might take to address health care custody because ICE is a federal program. Add- inequity. Who do we serve/who is already in our coming to the confusion, many states have reported they were unaware that some of their federally munities? Some churches and health care systems allocated doses of the vaccine were meant for de- already have large immigrant populations among tainees.21 Little data exists on how many detainees the people they serve and are therefore naturally have been vaccinated, but the number appears to plugged in to these communities. Others will have to consider how to go about building relationbe small. A responsibility ethics framework necessitates ships with immigrant communities. What needs exist in your town, city or comwe pay attention to how unjust relationships can be repaired by creating accountability and tak- munity? Not every community will have the same ing concrete responsibility for past injustices.22 needs. It’s important to know your own concrete In light of the way ICE detention centers have context. Who is already doing the work? What orgafailed to keep detainees as well as employees safe

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nizations or groups are working to provide services to immigrants or protect and promote immigrant rights? How can we build relationships with these groups? How can we respect, support and bolster the work already being done? What resources exist in our community or broader social network? Is there an immigration lawyer in our congregation who might be willing/ able to provide legal advice or help people understand how laws impact them? A medical professional who might know the local health care landscape and help people navigate it safely and comfortably? Does our building have space and amenities that might be able to house someone? AIMEE ALLISON HEIN earned her PhD in Theological Ethics from Boston College in February 2021. She currently teaches at Boston College. NOTES 1. Joey Peters, “Fearing Retaliation, Some Immigrants Stay Away from Public Aid,” NPR, December 9, 2019, https://www.mprnews.org/story/2019/12/09/fearingretaliation-some-immigrants-stay-away-from-publicaid. 2. Caroline Chen and Maryam Jameel, “False Barriers: These Things Should Not Prevent You From Getting a COVID Vaccine,” ProPublica, April 1, 2021, https://www. propublica.org/article/false-barriers-these-thingsshould-not-prevent-you-from-getting-a-covid-vaccine. 3. Bill Hutchinson, “Rite Aid Apologizes after Undocumented Immigrants Denied COVID-19 Vaccine,” ABC News, March 21, 2021, https:/ abcnews.go.com/ US/rite-aid-apologizes-undocumented-immigrantsenied-covid-19/story?id=76590963. 4. “A Message to the UTRGV Community Regarding Vaccine Distribution,” University Updates/Resources Related to COVID-19, The University of Texas Rio Grande Valley, February 25, 2021, https://www.utrgv.edu/coronavirus/vaccine-updates/2021-02-24/index.htm. 5. Akilah Johnson, “For Immigrants, IDs Prove to be a Barrier to a Dose of Protection,” The Washington Post, April 10, 2021, https://www.washingtonpost.com/ health/2021/04/10/covid-vaccine-immigrants-id/. 6. Charles E. Curran, The Catholic Moral Tradition Today: A Synthesis (Washington, D.C.: Georgetown University Press, 1999), 77. 7. Charles E. Curran, “Responsibility in Moral Theology: Centrality, Foundations, and Implications for Ecclesiology,” The Jurist 31, no. 1 (1971): 115. 8. Donald Kerwin et al., “US Foreign-Born Essential Workers by Status and State and the Global Pandemic,”

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Center for Migration Studies, May 2020, https://cmsny. org/wp-content/uploads/2020/05/US-Essential- Workers-Printable.pdf. 9. Sarah Varney, “Anti-Immigrant Vitriol Complicates Vaccine Rollout in Southern States,” Kaiser Health News, February 16, 2021, https://khn.org/news/article/antiimmigrant-vitriol-complicates-vaccine-rollout-in-southern-states/. 10. Margaret Urban Walker, “Making Reparations Possible: Theorizing Reparative Justice,” in Theorizing Transitional Justice, eds. Claudio Corradetti, Nir Eisikovits and J. V. Rotondi (London: Ashgate, 2015), 215-19. 11. Joseph H. Wu, Stephen D. John, and Eli Y. Adashi, “Allocating Vaccines in a Pandemic: The Ethical Dimension,” The American Journal of Medicine 133, no. 11, (2020): 1242. 12. “DHS Statement on Equal Access to COVID-19 Vaccines and Vaccine Distribution Sites,” Department of Homeland Security, released February 1, 2020, https:// www.dhs.gov/news/2021/02/01/dhs-statement-equalaccess-covid-19-vaccines-and-vaccine-distribution-sites. 13. Varney, “Anti-Immigrant Vitriol.” 14. Tim Henderson, “Churches, Community Groups Help States Vaccinate Immigrants,” Stateline, March 9, 2021, https://www.pewtrusts.org/en/research-and-analysis/ blogs/stateline/2021/03/09/churches-communitygroups-help-states-vaccinate-immigrants. 15. Mark Kuczewski, “DACA and Institutional Solidarity,” in Catholic Bioethics and Social Justice: The Praxis of US Health Care in a Globalized World, eds. M. Therese Lysaught and Michael McCarthy (Collegeville, MN: Liturgical Press, 2018), 190. 16. Kuczewski, “DACA and Institutional Solidarity,” 194. 17. Kuczewski, “DACA and Institutional Solidarity,” 195. 18. John Washington, “ICE Mismanagement Created Coronavirus ‘Hotbeds of Infection’ in and Around Detention Centers,” The Intercept, December 9, 2020, https://theintercept.com/2020/12/09/ ice-covid-detention-centers/. 19. Maria Sacchetti, “ICE has No Clear Plan for Vaccinating Thousands of Detained Immigrants Fighting Deportation,” The Washington Post, March 12, 2021, https:// www.washingtonpost.com/immigration/ice-detaineescovid-vaccine/2021/03/12/0936ee18-81f5-11eb-81dbb02f0398f49a_story.html. 20. Washington, “Coronavirus `Hotbeds of Infection’.” 21. Nicole Einbinder, Angela Wang and Daniel A. Gross, “After an Insider Investigation, ICE Reverses its Claim that It Asked States to Vaccinate Detained Immigrants,” Business Insider, February 23, 2021, https://www. businessinsider.com/ice-walks-back-covid-vaccineclaim-deflects-responsibility-2021-2. 22. Walker, “Making Reparations Possible,” 215-19.

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A G E F R I E N D LY

‘Old Age: Our Future’

VATICAN CALLS FOR NEW VISION IN CARING FOR THE ELDERLY

ope Francis, in his encyclical “Fratelli Tutti,” said of COVID-19 deaths among older adults, “they did not have to die that way,” pointing out that, “older people found themselves cruelly abandoned.”1

The experience of older adults during the pandemic and what has been learned over the past year are also discussed in “Old Age: Our Future — The Elderly After the Pandemic.”2 Old age, says the paper, is not a disease, but a blessing: “Being elderly is a gift from God and a JULIE huge resource, an achievement to be safeguarded with care, TROCCHIO even in case of disabling illnesses. ... And it is undeniable that the pandemic has given strength to our awareness that the ‘wealth of years’ is a treasure to be valued and protected.” The plight of older people during the pandemic was terrible. Not only were the rates of disease and death higher than any other population, but lockdowns in nursing homes and other facilities led to loneliness and isolation, further worsening health. The document points out that older people living in families seemed more protected.

conditions for the elderly to live this particular stage of life where they have been for a lifetime, at home with one’s family if possible and with lifelong friends.” In this vision, homes may need to be adapted to the needs of the elderly, such as removing architectural barriers. Services delivered in the home will be important, as will new technologies and advances in telemedicine and artificial intelligence that may let elderly persons stay in their homes or those of their families. For elders to live at home, families will need support because caring for loved ones takes energy and money. “A wider network of solidarity must be reinvented, not necessarily and exclusively based on blood ties, but on affiliations, friendships, common feeling and mutual generosity,” the document explains. Some older persons will need nursing homes and residential care, but these facilities should be reformed. Changes need to go well beyond offering fewer beds in a facility or providing picturesque gardens. “Effective reforms should have as

A NEW VISION

Some older persons will need nursing homes and residential care, but these facilities should be reformed. Changes need to go well beyond offering fewer beds in a facility or providing picturesque gardens.

The demographics of aging, according to the paper, show a need for serious reflection. While expanded life expectancy has been a great achievement of science and medicine, society has not adapted. “What we need is new vision, a new paradigm that helps society as a whole to care for the elderly.” Central to the new vision laid out in the document is keeping older people at home, saying, “Every effort must be made to enable the elderly to live in a ‘family’ environment during this phase of life.” It also details a “duty to create the best

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their principal goal the personalization of social and health and welfare initiatives,” the document advocates, adding that “independent living, assisted living, co-housing and all those initiatives inspired by the value proposition of mutual assistance must be promoted with creativity and intelligence while still making possible for the elderly a life that is autonomous and independent.”

VALUE ELDERS

Despite frailty, the elderly play a role in the preservation and transmission of the faith and in understanding life as a whole. “If life is a pilgrimage to the mystery of God, old age is the time when most naturally one looks to the threshold of this mystery.” The paper specifically urges the young to get to know the old. Pope Francis has frequently told young people to stay close to their grandparents, saying in an address on July 26, 2020, “Dear young people, each of these elders is your grandfather! Do not leave them alone! Use the imagination of love, make phone calls, video calls, send messages, listen to them …. Send them a hug.”3 “Old Age: Our Future” builds on the benefits of uniting the young and old, saying, “If the two generations can manage to meet, they can bring into the body of society that new sap of humanism that would make society more supportive.” It also invites dioceses, parishes and all ecclesial communities to reflect more attentively on the great world of the elderly, “Taking care of the spirituality of the elderly, of their need for intimacy with Christ and sharing of faith is a task of charity in the Church.”

NOT UTOPIAN

The paper concludes by saying that the vision it describes is not an abstract utopian pretense. Instead, it can “bring to life and nourish new and wiser public health policies and original proposals for a welfare system for the elderly. More effective, as well as more human. This requires an ethic of the public good and the principle of respect for the dignity of every individual, without distinction, not even that of age.” CHA, Catholic Charities USA and the Community of Sant’Egidio — a lay Catholic association dedicated to social service — teamed up to pro-

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ome themes and lessons from the Vatican document “Old Age: Our Future” The pandemic gives us the occasion to learn from past mistakes and plan for the future. Elderly in nursing homes fared very poorly — up to half the European deaths were in nursing homes. Old age should not be seen as a disease, but as a blessing. Learning to honor older people is necessary for our future. The role of caregivers should be given greater importance. Young people and older people can help and learn from each other. All spheres of society can play a role (culture, schools, volunteering, entertainment, manufacturing) in helping the elderly live at home.

mote “Old Age: Our Future” and its recommendations in a series of four webinars that included a description of the document, the implications of the pandemic on older adults, models for quality care and implications for the future. The archived webinar series, along with the Vatican document and other information, is at www.chausa.org/ eldercare/old-age---our-future. JULIE TROCCHIO, BSN, MS is senior director of community benefit and continuing care for the Catholic Health Association, Washington, D.C.

NOTES 1. Pope Francis, “Fratelli Tutti” (Rome: Vatican, 2020), 19. 2. “Old Age: Our Future — The Elderly After the Pandemic,” Pontifical Academy for Life and the Dicastery for Integral Human Development, February 9, 2021, http:// www.vatican.va/roman_curia/pontifical_academies/ acdlife/documents/rc_pont-acd_life_doc_20210202_ vecchiaia-nostrofuturo_en.html. 3. Pope Francis, Angelus address, July 26, 2020, http:// www.vatican.va/content/francesco/en/angelus/2020/ documents/papa-francesco_angelus_20200726.html.

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BOOK REVIEW

MEDICAL-RELIGIOUS PARTNERSHIPS COLLABORATE TO IMPROVE HEALTH JULIE TROCCHIO, BSN, MS

In recent years, we have seen health care change s if we hadn’t known, COVID-19 revealed that the oldest among us are the most vulnerable. from focusing mostly on acute problems to caring Seniors with chronic illness got sick, very sick for chronic illnesses. This means individuals have and died from COVID. Seniors living in nursing more of a role in and responsibility for their own homes represented about 40% of U.S. deaths from care. But patients, especially seniors, need help to the virus. Their lives were in jeopardy, the quality learn what they need to know about their medical conditions and how to manage of their lives suffered. their health. Health care organizaDid it have to be this way? Can tions and their clinicians cannot we better serve our seniors with do this by themselves. This book chronic illness? Can we offer altersuggests that faith communities natives to nursing homes? Can we and those in health care working help caregivers keep their loved together can provide that help. ones at home? Why should congregations Building Healthy Communities of people of faith get involved in through Medical-Religious Parthealth education? The authors say nerships is a practical book by a that faith communities (parishes, psychologist and two physicians, synagogues, mosques) have trewith commentaries by a chaplain, mendous potential to meet health intern and pastor, that offers posneeds of seniors because they sible answers. have the community resources Medical Religious Partnerships and communication networks describes relationships between that hospitals and other providheath systems and faith congreers don’t necessarily have. “No gations formed to meet many of BUILDING HEALTHY community institutions are better the difficult challenges of an aging COMMUNITIES THROUGH suited to serve as partners for hossociety. It is rich with program ex- MEDICAL-RELIGIOUS pitals … Congregations can be inamples and resources for provid- PARTNERSHIPS viting, encouraging, and informing services to seniors and their W. DANIEL HALE, PHD; RICHARD BENNETT, MD; AND PANAGIS ing, empowering people to take caregivers. proactive steps in the care of their In the foreword, Patricia Fo- GALIATSATOS, MD bodies, minds and souls.” sarelli, MD, DMin, says that in her Johns Hopkins University Press, Large numbers of older adults, experience, “people often perish Baltimore, 3rd Edition 2018, 280 pgs. many with chronic conditions, before their time because of lack gather regularly with their faith of accurate information about potential and existing health threats, or their lack congregation. Leaders in these environments of trust in medical institutions …” This book ad- know their congregations’ traditions and values dresses both problems: how to bring important and have the trust of their members. Most have health and resource information to those who excellent facilities, parking, and equipment for need it and how to have that information come programs and human capital such as retirees and from trusted sources that are deeply rooted in the other potential volunteers. The book opens with a story about a Presbytecommunity — religious congregations.

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rian pastor at Westminster By-The-Sea Church in Daytona Beach, Dr. Jeffery Sumner, who discovered he had diabetes at a health screening at his parish. After his diagnosis was confirmed, he became a regular participant of his church’s Body Mind and Soul program, a collaboration with a local hospital. Through classes, he learned about how harmful diabetes could be if not controlled and how to manage it. He found the health seminars and discussions with health professionals and members of the congregation to have a spirit of openness and trust. Similar programs offer classes on identifying warning signs and managing heart disease, stroke, cancer, diabetes, depression, dementia. Sessions also might cover managing medications, home safety and immunizations. Building Healthy Communities through Medical-Religious Partnerships describes several programs in the Baltimore area with the Johns Hopkins Hospital and its physicians. At the Southern Baptist Church guest lecturers speak about health from the pulpit, volunteers take blood pressures in the fellowship hall after services, and classes and screenings are provided in a nearby affordable housing project. At Baltimore’s Sacred Heart of Jesus Catholic Church — known to members of the growing Latino community as Sagrado Corazon de Jesus — the weekly bulletin has information about hypertension, diabetes and other health topics. Dr. Gerardo Lopez-Mena, a second-year resident at Hopkins who was seeing patients in the emergency room who did not know how to manage their medical conditions, began teaching Spanish-language health education classes. The city’s Beth El Congregation’s “Soul Center” has events for caregivers, including workshops, seminars and time to meet with others,

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demonstrating how these programs can offer family caregivers a safe environment for sharing concerns. The events give practical advice on getting the most out of medical appointments, keeping track of medications and watching for side effects. The book suggests topics and content that medical-religious partnerships can bring to congregations, including basic information on coronary artery disease, hypertension, lung disease, diabetes, kidney disease, cancer, child and adolescent health, vaccinations, advance directives, depression and dementia. It also features information that can be presented about modifying risk factors, communicating with health providers, managing medications, and preventing accidents and falls. An extensive resource section offers suggestions for tapping community resources and information available from national organizations. JULIE TROCCHIO, BSN, MS, is senior director of community benefit and continuing care for the Catholic Health Association, Washington, D.C.

ADDITIONAL INFORMATION Joe Eaton, “Who’s to Blame for the 100,000 COVID Dead in Long-Term Care?,” AARP, Dec. 3, 2020, https://www. aarp.org/caregiving/health/info-2020/covid-19-nursinghomes-who-is-to-blame.html. Johns Hopkins has created a supplemental website to the book. This is a practical guide for leaders of faith congregations and health care providers looking for solutions for older people and their caregivers. The site includes downloadable handouts and PowerPoint slides, https://www.hopkinsmedicine.org/about/ community_health/johns-hopkins-bayview/services/ healthy_community_partnership/building_ healthy_communities/index.html.

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COMMUNITY BENEFIT

HEALTH ANCHORS INVEST TO BUILD COMMUNITY WEALTH, IMPROVE WELL-BEING BICH HA PHAM, JD and DAVID ZUCKERMAN, MPP

he COVID-19 pandemic has caused dramatic job loss and business closures, disproportionately impacting lower-income groups and people of color. Communities that are financially struggling and historically disinvested have borne the brunt of the economic fallout, while funding to many local nonprofits and community groups has been cut. Despite the public health and fiscal challenges that hospitals and health systems have faced during COVID-19, these institutions have continued to invest in their communities because the health and well-being of children and families called upon them to act.

Nationally, health systems have an estimated $400 billion in investment assets.1 Redirecting even a small portion of these resources to local community investments would shift billions of dollars, allowing health care organizations to more effectively improve community health and well-being.

example is a health system moving a percentage of its investment portfolio allocation from public fixed-income products, such as bonds paying 2% to 3% return, to investing in the local community and obtaining a similar or slightly lower rate of return with the added benefit of positive social and/ or environmental impact.

LEVERAGING HEALTH INSTITUTIONS’ RESOURCES

CREATING POSITIVE CHANGE

Health systems are uniquely positioned as leading employers and economic engines in their communities. In adopting an anchor mission approach, these institutions leverage their resources to address the economic, racial and environmental resource disparities that impact community health outcomes, in addition to providing quality health care. Place-based impact investing, along with local inclusive hiring and local procurement, are key pillars for anchor mission implementation. Members of the Healthcare Anchor Network (HAN) intentionally use their everyday business activities — hiring, purchasing, investing — to address the disparities that affect health. Impact investing is a key resource in the toolkit that these systems can bring to their anchor mission efforts. The goal is to create sustainable returns for the institutions while deploying investment capital to address structural determinants of health needs in their communities by targeting positive social and environmental impacts. Unlike grants, impact investing comes with an expectation of return on the investment. A common

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Poverty and lower household income affects health. Economic inequality is increasingly linked to disparities in life expectancy. Low-income Americans face greater barriers to accessing medical care, have higher rates of heart disease, diabetes, stroke and other chronic conditions, and have higher rates of behavioral risk factors compared to higher-income Americans.2 Place-based investing creates healthy and thriving communities by investing in disadvantaged neighborhoods and increasing the available capital for social, economic or environmental improvements. It supports diverse business development and empowers low-income people to create, manage and own enterprises. It transforms community infrastructure, services and quality of life. These investments become a revolving pool of capital that will be leveraged several times over to have an even greater impact in communities nationwide. Note that this positive social impact investing differs from “negative screens” used in socially responsible investing that filters out sectors such as tobacco for investments.

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Place-based investing is distinct from grants or financial contributions in that there is an expectation of a return on the investment. However, impact investing can advance community benefit goals. For example, a health system may invest funds in a new affordable housing project as part of its community benefit strategy to address homelessness, along with its grants to homeless prevention nonprofit groups. The benefits of place-based investing advance four meaningful organizational goals: savings in unnecessary health care expenditures; economically improved and vibrant neighborhoods; advancements in environmental sustainability, diversity and inclusion; and reliable financial returns for the investment portfolio. In essence, a business case exists for pursuing social impact investing. Investments in affordable housing are a proven example of cost savings for hospitals. Unstable housing among families with children will cost the U.S. $111 billion in avoidable health and education expenditures over 10 years. New York City’s Montefiore Health System achieved a 300% return by investing in housing for patients who are homeless, a move that has cut down on emergency room visits and unnecessary hospitalizations. The Los Angeles County’s Housing for Health program saw a $1.20 savings in health care costs for every $1 invested in affordable housing for the patients.3

SOCIAL IMPACT INVESTING STRATEGIES

Hospitals and health systems can begin with fairly simple investment strategies, such as shifting deposits of cash and cash equivalents to local community banks and credit unions or by investing in low-risk fixed income products offered by community development financial institutions (CDFIs). Nonprofit CDFIs provide key financial services and resources to underserved communities. Over time, their integrated capital approach maximizes local impact by coordinating investments with grants, technical assistance and other supports. Even a 2% shift in health systems investing to CDFIs would be double the amount annually of the primary federal funding mechanisms for community development finance loans across the country.4

THE IMPACTS OF LOCAL INVESTING

Utilizing investment funds to increase the available capital for positive social, economic or environmental change has been embraced by the Catholic Impact Investing Collaborative, and many of the HAN member Catholic health systems are engaged in impact investing. Here is a brief overview of the impactful work of several Catholic health systems: Bon Secours Mercy Health (BSMH) has allocated 1% of the system’s long-term investment portfolio, about $50 million, to place-based investments. As the system operates across multiple

Source: Healthcare Anchor Network

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states, efforts are in place to ensure that these investments align with the system’s geographic footprint. This is the health system’s “direct community investment” strategy, supporting institutions or projects to promote access to jobs, housing, food, education and health care for lowincome or minority communities. Staff from Treasury and Finance, and Community Health collaborate on this work. Current examples of place-based investments are: Bons Secours Mercy Health invested $900,000 with the Leviticus Fund that, at the time of the original loans, operated in the region served by three Bon Secours hospitals. The Leviticus Fund, a New York-based CDFI, used the funds to develop 14 affordable housing units for formerly homeless veterans and to partner with a land bank to develop four properties to create owner-occupied rental units. Bon Secours Mercy Health also is set to extend loans totaling more than $2.5 million in three additional markets. Investments will support new housing developments, greater access to loans for prospective homeowners and sustainable capital pipelines for minority- and women-owned business ventures. Some key strategies or investment vehicles Bon Secours Mercy Health uses are intermediary investments (CDFIs) and aligning community benefit with place-based investing strategies. When possible, BSMH layers grant dollars with loans. CommonSpirit Health’s Community Investment Program has provided about $250 million over 30 years to support economic development in low-income communities. Nearly 45% of the funds are invested in affordable housing. Dignity Health, now part of CommonSpirit Health, made direct and indirect loans to invest in projects that addressed community needs, such as affordable housing, economic development, renewable energy, arts and education, alternatives to predatory lending and health care access. About a quarter of Dignity’s community investment portfolio was invested in partnership with CDFIs.5 The New York Times also wrote about Dignity’s $1 million loan to La Cocina, a nonprofit

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that helps women of color entrepreneurs start catering and restaurant business.6 Trinity Health’s Direct Community Investment Program has allocated $75 million for social impact investments. Already, $37 million in loans have been made in 16 states, and $9 million has been committed in loans to other projects to support affordable housing, access to healthy food and access to higher education. Trinity Health works both with CDFIs and through programrelated investments made directly to projects and programs in Trinity Health communities. The health system seeks projects that leverage its investment to bring on additional capital, typically sevenfold to tenfold. Some examples of Trinity Health’s recent affordable housing investments include: A $1 million investment in Cinnaire, a CDFI serving the Midwest and Delaware, to finance the acquisition and renovation of vacant and blighted properties in distressed neighborhoods in Wilmington, Delaware. A loan of $1 million to support the construction of Canyon Terrace, an 80-unit affordable housing development in Nampa, Idaho, targeted to families and individuals making 60% of area median income.7 Providence has a Community Investment Fund that provides capital in the form of loans, deposits or other support to nonprofit entities to promote social good and the development of healthier communities. These loans enable community organizations that serve low-income and other vulnerable populations to play a larger role in the regeneration of their communities. Some of the programs that have received support include affordable housing, economic development and social service programs, food programs and other direct service programs, and educational and job expansion initiatives.8 Just two examples of the health system’s placed-based investing efforts that totaled more than $9 million in loans include: Providence Home and Community Care, which supports Providence Dolores House, a 16-unit, 30-bed housing project for low-income individuals with disabilities. Jamboree Permanent Supporting Housing,

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where bridge funding was granted in 2019 until permanent financing was available in 2020 for the purchase and conversion of an Econo Lodge to permanent supportive housing units.9 Ascension has committed almost $90 million to impact investing, focused on two objectives: improving access to social goods and services to the poor and vulnerable through investments in areas such as clean water, food and nutrition, adequate and affordable housing and education, health and health care, and financial services. And environmental stewardship, giving priority to private funds that have a track record of excellent performance in environmental conservation and/or a focus on innovative green products, services or processes. The HAN website contains several resources, including the Place-Based Investing Toolkit, to help accelerate anchor mission strategies.10 In addition, the Investing in Community Health: A Toolkit for Hospitals developed by the Catholic Health Association11 and Center for Community Investment12 provide health care organizations information and resources to maximize their impact on community health through their investment capital. BICH HA PHAM is director, communications and policy for the Healthcare Anchor Network. DAVID ZUCKERMAN is executive director of the Healthcare Anchor Network. NOTES 1. “Place-Based Investing: Creating Sustainable Returns and Strong Communities,” Democracy Collaborative, https://hospitaltoolkits.org/investment/. 2. Dhruv Khullar and Dave A. Chokshi, “Health, Income, & Poverty: Where We Are & What Could Help,” Health

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Affairs, October 4, 2018, https://www.healthaffairs.org/ do/10.1377/hpb20180817.901935/full/. 3. Sarah B. Hunter et al., “Evaluation of Housing for Health Permanent Supportive Housing,” Rand Corporation, 2017, https://www.rand.org/pubs/research_ reports/RR1694.html. 4. “Place-based Investing,” Health Anchor Network, https://healthcareanchor.network/2019/11/ place-based-investing/. 5. Pablo Bravo Vial, “Boundless Collaboration: A Philosophy for Sustainable and Stabilizing Housing Investment Strategy,” Health Progress 100, no. 5 (SeptemberOctober 2019), https://www.chausa.org/publications/ health-progress/article/september-october-2019/ boundless-collaboration-a-philosophy-for-sustainableand-stabilizing-housing-investment-strategy?mc_ cid=68a7d0b3c3&mc_eid=9f7e2e4412. 6. Peter S. Goodman, “When a Steady Paycheck Is Good Medicine,” The New York Times, October 10, 2019, https://www.nytimes.com/2019/10/10/business/ healthcare-anchor-network.html. 7. James Kienker, email to author, March 10, 2020. 8. “Annual Report to Our Communities,” Providence St. Joseph Health, Community Investment Fund, https:// www.stjhs.org/our-programs/community-partnerships/ community-investment-fund/. 9. Cassie Tinari, email message to author, February 17, 2020. 10. “Resources,” Healthcare Anchor Network, https:// healthcareanchor.network/anchor-mission-resources/. 11. “Investing in Community Health: A Toolkit for Hospitals,” Catholic Health Association, https://www.chausa. org/communitybenefit/social-determinants-of-health/ cha-resources. 12. “Investing in Community Health,” Center for Community Investment, https://centerforcommunity investment.org/.

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ETHICS

TECHNIQUES TO FOSTER INTER-RELIGIOUS DIALOGUE MAY ASSIST CLINICAL ETHICISTS

or more than two decades, clinical ethicists have continued to define their profession more clearly. This conversation includes the creation of professional standards, licensing and accreditation, goals, skills and ultimately the role of the clinical ethicist in health care. Many discussions among leaders in the profession affirm a model of ethicist as a mediator — one who creates conversation between interested parties and guides them to an acceptable solution.1 Mediation is a “private, vol- ator will empower all members to speak their conuntary, formal process in which cerns and to listen attentively to the needs of the an impartial third person facili- others. Mediation requires communication skills, tates a negotiation between peo- pastoral skills, knowledge about health care sysple in conflict and helps them tems and policies, and expertise in bioethical thefind solutions that meet their ories. Even though I believe that these are strong interests and needs.”2 A media- skills for the ethicist to know, I wonder whether tor may help in small claims dis- other fields might provide useful knowledge. NATHANIEL I propose the field of inter-religious dialogue putes or in major international BLANTON conflicts. They gather facts, but as one of many models from which clinical ethinot to determine who is right cists can learn valuable lessons, including how to HIBNER and who is wrong. Rather, the be better facilitators. Examining the work of intermediator gathers the information to reveal how religious dialogue reveals similar goals, particieach party “experienced the event that brought pants, struggles and needs. Since the Second Vatican Council and the docthem to mediation.” The goal of mediation is not to judge either ument, Nostra Aetate, the Church is, “ever aware party or his or her version of the facts. The goal of its duty to foster unity and charity among inis to discover the “reality that can accommodate the coinciding and conThe goal of mediation is not to judge flicting interests and needs of the either party or his or her version of participating parties.” The mediator wants a resolution that is “comfortthe facts. The goal is to discover the able with all the parties” and leaves the group feeling assured that their “reality that can accommodate the concerns were heard.3 coinciding and conflicting interests In the clinical setting, the consulting ethicists must combine clinical and needs of the participating knowledge with the skills of mediaparties.” tion.4 They may be called on to handle disputes among the care team, between the patient and physician, to deliver ter- dividuals …”5 In 1996, a Catholic group led by the rible news, or to clarify the treatment plan and late Cardinal Joseph Bernardin founded an initiaoutcomes. Since they are most likely paid by the tive to promote the study and practice of interhospital, the mediator must assure all parties that religious dialogue. The group, named the Cathothey are truly neutral to the conflict. A good medi- lic Common Ground Initiative, supports lectures,

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publications, course planning and conferences that gather leaders of various religions for honest conversation and cooperation. After several years of leading the charge, the Catholic Common Ground Initiative shared the principles it believes can foster good dialogue.6 These principles can ensure honesty, compassion, goodwill and charity among all parties. They are designed to keep the dignity of each member at the forefront and to prevent the continuation of ill will. I wish to examine three of the principles that I believe can help ethicists fulfill their role within the clinical setting. “We should put the best possible construction on differing positions, addressing their strongest points rather than seizing upon the most vulnerable aspects in order to discredit them.” During an ethics consultation, the ethicist must affirm the importance of all people’s contributions. Nancy Neveloff Dubler and Carol B. Liebman offer the technique of “stroking” — “acknowledging feelings” and “recognizing the work of the participants.”7 Essentially, they propose using positive and supportive language. The Catholic Common Ground Initiative asks that we “detect the valid insights and legitimate worries that underlie even questionable arguments.”8 These actions express the active listening of the mediator and the desire to understand the speaker. “We should be cautious in ascribing motives.” The Catholic Common Ground Initiative provides greater clarity: “We should not rush to interpret disagreements as conflicts of starkly opposing principles rather than as differences in degree or in prudential pastoral judgments about the relevant facts.”9 This principle attempts to prevent actors from diving deeper behind the suggestions of the other. It keeps the focus on the conversation instead of the history between the parties. It strives to hope for similarities, instead of differences. “We should bring the church to engage the realities of contemporary culture, not by simple defiance or by naive acquiescence, but acknowledging, in the fashion of Gaudium et Spes, both our culture’s valid achievements and real dangers.”10 This principle appears at first glance to be separate from the bioethical field. But when we analyze it and come to understand the reasoning behind the

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principle, we learn a very powerful lesson — the need to engage the social, cultural and historical backgrounds of a given conversation. The field of clinical bioethics continues to have an identity problem. The debate about defining the goals, standards and education of ethicists is worthwhile. The literature seems to be moving toward a model of ethical facilitation grounded in the practice of mediation. If this direction continues, members of the field would be wise to look beyond themselves to find models with similar goals and practices. Inter-religious dialogue is a model with a bounty of treasure from which clinical ethics can benefit. NATHANIEL BLANTON HIBNER, PhD, is director, ethics, for the Catholic Health Association, St. Louis. NOTES 1. American Society of Bioethics and the Humanities, Core Competencies for Healthcare Ethics Consultation (Chicago: 2011). A note for readers: Clinical ethicists have been undergoing the process of professionalization, which started in the 1990s. It includes certain competencies, standardized education, defined roles and can include certification. 2. Nancy Neveloff Dubler and Carol B. Liebman, Bioethics Mediation: A Guide to Shaping Shared Solutions, revised and expanded edition (Nashville: Vanderbilt University Press, 2011), 604. 3. Dubler and Liebman, 641. 4. Dubler and Liebman, 629. 5. Second Vatican Council, “Nostra Aetate: Declaration On The Relationship Of The Church To Non-Christian Religions,” https://www.bc.edu/content/dam/files/ research_sites/cjl/texts/cjrelations/resources/ documents/catholic/Nostra_Aetate.htm, No. 1. 6. Catholic Common Ground Initiative, “Principles of Dialogue,” https://catholiccommonground.org/ principles-of-dialogue/. 7. Dubler and Liebman, 87. 8. “Principles of Dialogue.” 9. “Principles of Dialogue.” 10. “Principles of Dialogue.” Gaudium et Spes is a document from the Second Vatican Council that outlines the role of the Catholic church in relationship with the broader world. It recognizes that the Catholic church has a mission to address the needs of those outside the Catholic faith.

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

THE GUIDING PRINCIPLES

C BRUCE COMPTON

HA is celebrating the fifth anniversary of the Guiding Principles for Conducting Global Health Activities, reflecting on each of the six principles and how they are being lived today. In this column, we look at the principle of authenticity through the personal experiences of a good friend of mine, Dr. Shailey Prasad. He has had to consider his personal motivations for the global health work he’s conducted and shares a story that begs us to question our own authenticity, our own motivations.

The personal desire to alleviate suffering is real for individuals as much as for our ministries as large entities trying to be of service to communities across the world. We, too, must be authentic in our actions, in stating our primary and secondary goals, and in our own discernment around how we behave as partners. Do we see our hosts as equals? Do we listen to their needs? Do we explain our own needs and purposes? Catholic health care in

the U.S. was founded by brothers and sisters from foreign lands who came to this fledgling country on global health missions. Their authenticity was easy to see, as they came with one-way tickets and lived as a part of the communities they served. We, too, can be authentic in new and innovative ways, in the short-term medical missions, parish twinning for mutual capacity building and other partnerships. It’s essential to being who we say we are as ministries of the church.

AUTHENTICITY SHAILEY PRASAD, MBBS, MPH

remember the frustration; there was perhaps anger, too. In front of me was an elderly tribal leader, grizzled hair, deep creases on his face telling untold stories of life not recorded on any calendar. And I was letting him have it, essentially haranguing him for not coming in earlier. He had brought his wife to be examined since she was not eating well. My examination had revealed an emaciated, middle-aged woman with a rock hard mass in her abdomen. In this remote forest area of southern India, I had no specialized equipment to come to a diagnosis. I knew that this was quite likely a malignancy, and I was taking my frustrations out on this elderly man in front of me. After I simmered down, as I was sitting at my desk, contemplating what I needed to do next, the elderly man approached me and asked me if I was OK. And just before my frustrations climbed up to the top again, he mentioned, “She is dying, right? We know it. We are at peace. We are forest

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dwellers, here one day, gone the next. I know you want to help, but we are fine.” It was as if someone had hit a reset button inside me. I was thinking too technically during the encounter, looking at the woman with the specific skills that I had. I was not bringing my authentic self and was imparting an arrogance, built by my medical training and privilege.

WORKING IN GLOBAL HEALTH

Often in health care, and particularly in global health, we are faced with dire scenarios in which uncertainty and resource limitations are inherent. In such situations, we tend to lean toward technical skills; they are our solace, the concrete work that gives us a bearing. The “What?’’ and “How?” light a path for the technical work we do. And, the technical work bulldozes all other thoughts and builds justifications for continued work. It is precisely in this phase that we need to pause and

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one’s authentic self. Our ask the deeper “Why?” quesjourney through life is tions. one of discovering and reQuite often the drivers evaluating our actions and that motivate us to engage choices. It is a wonderful in global health may start journey on which we expewith an emotional response rience a host of emotions to a particularly dire situathat give us information to tion or a compelling need shape our thoughts. But if to help. These are, after all, those thoughts do not develthe best of emotions that op or are not guided by our define who we are as empamoral compass, they tend thetic individuals. However, Know thyself, know thy partner to have a stunted existence, it has been the experience one that will let us continue of a lot of those engaged in There are many motivations for to function purely from a global health, including me, U.S. and international technical skills viewpoint. that many of these well-inorganizations to engage in Our authentic self manifests tentioned activities end up international health activities. An when our life aligns with the causing more problems. In invitation from a true partner who actions and there is a deep this context, one has to look is part of the local community and understanding of the “why” at the activities and ask the in the work that we do. It is question “Why?” Why are we its health system, knowledge then we can authentically doing this? Why is this hapand understanding of our express ourselves as who we pening? And so on. I would respective motives and full are, not what we do. posit that one of the main transparency regarding our goals I have found taking the challenges could be that are all necessary if we are path of self-discovery, of starting with the “to help” to do our best work. finding authenticity in the framework blinds one from work that I do, important asking the deeper “Why?” but not always clear. It is questions. It inherently creates a power dynamic that sets up a top-down ap- then that I remind myself of part of a David Whyte proach. This power differential could then be a poem: root of other problems, including creating depen“Start close in, dency structures and boosting one’s own ego. It don’t take the second step would then behoove us to approach global health or the third, activities in the framework of a humble learner, start with the first where intellectual curiosity and genuine apprething ciation of individuals and communities in global close in, health settings give us the opportunity to grow as the step people. you don’t want to take.”

AUTHENTICITY

UNDERSTANDING ONE’S AUTHENTIC SELF

In the course of our growth and development as individuals, we are guided by a moral compass— the ability to differentiate between right and wrong. The full manifestation of this may be different in different people. The compass guides us through our choices as we look at various imputations of our actions and discern the path forward. It is also important to keep in mind that the more we look at these choices, the more we understand the nuances of the work in front of us. This moral compass is the underpinning of

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And hopefully every such step that I take will allow me to understand and express my authentic self. DR. SHAILEY PRASAD is the executive director of the University of Minnesota Center for Global Health and Social Responsibility and the vice chairman for education at the Department of Family Medicine and Community Health in Minneapolis.

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P R AY E R

SERVICE

A Prayer for Our Families LORI ASHMORE-RUPPEL DIRECTOR, SPONSOR SERVICES, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

CALL TO PRAYER Leader: Our experience of the pandemic has changed many aspects of our lives, perhaps most especially, our relationships — with family, friends, coworkers, even ourselves. Many of us have been home with spouses, children or parents, working together and competing for attention in ways we have never had to before. Others have spent day after day with only virtual company, longing for physical touch and tangible expressions of care. Like no other time in our lives, this time has brought some blessings, but also has been a cause for anxiety. Pope Francis wrote the apostolic exhortation, Amoris Laetitia, on love in the family five years ago. In 2021, the Church began the Amoris Laetitia Family year to bring focus to the family as a vocation and a pathway to holiness, especially in light of the pandemic. Let us listen and reflect on the words of Pope Francis. Reader 1: “I thank God that many families, which are far from considering themselves perfect, live in love, fulfill their calling and keep moving forward, even if they fall many times along the way … there is no stereotype of the ideal family, but rather a challenging mosaic made up of many different realities, with all their joys, hopes and problems.” [Amoris Laetitia 57] Leader: Take a moment to reflect. When in this last year have you faced challenges and found joy in the life of your family? Reader 2: “The life of every family is marked by all kinds of crises, yet these are also part of its dramatic beauty. Couples should be helped to realize that surmounting a crisis need not weaken their relationship; instead, it can improve, settle and mature the wine of their union. Life together should not diminish but increase their contentment; every new step along the way can help couples find new ways to happiness.” [232]

Leader: Let us again reflect. When in this last year have you faced a crisis and found a relationship strengthened? Reader 3: “All family life is a ‘shepherding’ in mercy. Each of us, by our love and care, leaves a mark on the life of others … Each of us is a ‘fisher of men’ who in Jesus’ name ‘casts the nets’ to others, or a farmer who tills the fresh soil of those whom he or she loves, seeking to bring out the best in them … this is itself a way to worship God, who has sown so much good in others in the hope that we will help make it grow.” [322] Leader: Take a moment to reflect. When in this last year have you left a mark on others that has given them a new hope? When have others left a mark on you that brought forth new hope? As it feels appropriate, spend some time in conversation as a group. Leader: Let us pray. Heavenly Father, We pray in gratitude for the example of the Holy Family of Nazareth. May we continue to look to them for guidance as we nurture our family life in our journey to holiness. We pray in gratitude for our loved ones, both near and far, who strengthened and supported us through the challenging times of the last year. May we continue to grow in our relationships as we find new ways to happiness. As we await the end of this pandemic, we look to you for healing of our grieving hearts and hold fast in our faith that the family we lost are now with you. Amen.

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

SUMMER 2021

www.chausa.org

HEALTH PROGRESS

To celebrate the 5th Anniversary of CHA’s Guiding Principles for Conducting Global Health Activities, CHA HAS TWO NEW RESOURCES! A 5th Anniversary Edition of the Guiding Principles INCLUDES A MODERN DAY PARABLE ON PANDEMIC

An essay collection to help us rethink, reset and reengage in Global Health activities! Among the many influential voices in global health, authors include Cardinal Peter Kodwo Appiah Turkson, Prefect of the Dicastery for Integral Human Development, and Andrew S. Natsios, former administrator of the U.S. Agency for International Development.

ACCESS THEM AT CHAUSA.ORG/GLOBALHEALTH

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

Health Progress - Summer 2021

Articles inside

THINKING GLOBALLY The Guiding Principles

PRAYER SERVICE

ETHICS Techniques to Foster Inter-Religious Dialogue May Assist Clinical Ethicists

HEALTH EQUITY Responsibility Ethics in the Age of Coronavirus

BOOK REVIEW

COMMUNITY BENEFIT Health Anchors Invest to Build Community Wealth, Improve Well-Being

MISSION COVID, Community and Catholic Identity

A FORMATION ECOLOGY FOR THE DIGITAL AGE

CHRISTUS HEALTH STRIKES BALANCE TO PROVIDE SAFE LOVING SUPPORT FOR PATIENTS

FEELING BOXED IN, AND MOVING BEYOND IT

ADVANCING PATIENT-CENTERED CARE BRINGING SOCIAL SUPPORT INTO THE FOLD

COVID PULLS BACK THE CURTAIN ON SOCIETAL PLIGHT

FINDING OUR WAY, TOGETHER

FINANCIAL PROGRAMS FOR OUR WORKERS THE ULTIMATE RETURN ON INVESTMENT

AS SCHOOLING SHIFTS, WHAT WORKS TO EDUCATE KIDS AND KEEP THEM HEALTHY?

EDITOR’S NOTE