How (Not) To Grieve

— I was taught not to cry at death. And it fucked me up.

Mitchell S. Jackson in Los Angeles, March 9, 2024

The homie Kev was kind, smiled easy, and spoke so soft sometimes I had to lean in to hear him. The homie Kev was cock-diesel and fearless on the football field. The homie Kev took the rap for me without a blink when my grandmother caught me packaging bunk weed in my bedroom.

The fall after we graduated, my homie Kevan Hai Miller was found shot to death on an apartment doorstep. What I remember is feeling my response should be governed by my manhood, that I’d be weak if I wept, whether someone saw my eyes leak or not. I’d had practice in not grieving. Going into my senior year, our fireplug point guard had beef with my cousin—not my blood, but our mothers were super close—and shot him. My cousin, amen, lived. And yet we might’ve been more worried about losing our PG for the season than the gravity of such serious violence. We were teenage boys, most of us Black, considering extreme harms, but almost no one was dramatic about it. While grieving forreal forreal would’ve been seen as Hamletian histrionics, fear lay beneath our forged stoicism: Which side of the fray were we on? Were we, too, in peril? Did the circumstances demand our swift vengeance?

To grieve or not to grieve? Often the answer was a mandate: Shake that shit off pronto. We did, however, commemorate the dead homies with ample reminiscing, often while getting faded on weed or liquor. Pouring some of that liquor on a curb. Wearing T-shirts screen-printed with a picture of the deceased. A barbecue or picnic in their honor. A curbside memorial. And for the most brazen: murderous-minded get-back.

None of our rituals amounted to the five stages of grief expressed by Elisabeth Kübler-Ross in On Death and Dying: denial, anger, bargaining, depression, and acceptance.

Denial has always felt like a weakness. Why the hell am I denying what happened, the absolute fact of someone’s death? People get killed. People die from cancer or a seizure or a heart attack or Covid, and while it hurts to lose them, it seems irrational if not insane to protest the reality. The same goes for bargaining, which I’ve also been determined to skip. Why bargain against what can’t be undone? Who am I bargaining with, the deity that allowed it? The same goes for depression, for my refusal to allow that a significant loss could leave me down, down, that my despair is natural and maybe even healthy. My grieving has meant speeding to acceptance, even if I know in my deepest and truest place that acceptance is false. My mourning has been bound by what I’ve been nurtured to believe about the intersections of manhood and blackness—by Black manhood—and those beliefs have made it all but impossible to progress through healthy grieving.

A Black man is ever strong. A Black man don’t cry—he damn sure don’t do no public boohooing. A Black man don’t broadcast his feelings. A Black man don’t cower from anything or anyone. A Black man handles it, whatever it may be.

On the flipside of that armored, unflappable, immutable Black manhood is, God forbid, the jacket of a lame or a sucker or a punk or a pussy or a bitch or soft or weak; is, God forbid, the disgrace of being deemed a man who let his emotions get the best of him, or in other words, a man who let his emotions escape outside of him.

A Black man don’t cry—he damn sure don’t do no public boohooing. A Black man don’t broadcast his feelings.

Much of our rubric is cultural. But somebody please show me a part of culture that isn’t also historical.

If epigenetics is real, mightn’t Black grief be shaped by the forbearers of Black Americans having survived the torture of a speculum orum or a dead fellow African coffled to them or a beloved tossed into the Atlantic without a care. Their kin snatched from their outstretched arms and sold to an eternal elsewhere. Their flesh and blood strung from a sturdy branch and beaten or flayed or castrated or set aflame? Their intimates lost to post–Civil War privation or prison cells? Yeah, slavery was ages ago, but if epigenetics is true, how might those traumas have shaped the descendants of the once enslaved?

Not to mention what to make of the collective grief of Black people who witnessed Mike Brown left baking in the street. Eric Garner choked unconscious. George Floyd kneeled into the next life. Tell me, what might those almost inescapable Black traumas do to the genes of Black folks writ large? How might they shape Black men who feel beholden to rigid strictures of manhood?

A case study of three recent personal losses.

November 6, 2022—Fresh off a transatlantic flight, I received a rare call from my sister. “Mitch, Dad passed,” she said. “Dad is gone. Dad is gone.” When I hung up, I watched dreary London lapse past my window and sobbed in silence. That commute wasn’t the only time I wept over my 67-year-old biological father (Wesley Johnson Sr.) dying in his sleep from a seizure, but it was the only time I allowed myself tears without a measure of self-chiding.

July 17, 2023—My beloved Aunt Bonnie had a heart attack and died in her sleep. Just that May, my aunt texted about a dream in which, while she was struggling to write, someone asked her if she knew me. Aunt Bonnie told the person in her dream that she did, and they advised her to have me touch her pen. Aunt Bonnie asked me to bring her pens, “speak a few words over them,” and leave them in her mailbox. The next day, I delivered her a pack of pens and a Moleskine notepad, inscribed, “I pray you take your ambitions all the way!” Aunt Bonnie assured me, “I’m really going to write that memoir this time, nephew.” Months after she died, I returned home from a trip and discovered my cousin had sent me a package with the Moleskine. On its first page, Aunt Bonnie (Bonnie Johnson) had written an account of her dream and of me dropping off the notebook. She ended it, “I will write. I will write. I will write. Nephew, thank you for showing up for the assignment.” Because I was alone, I let myself weep without reserve, the last I lamented her passing without wondering if it had lasted too long.

January 15, 2024—My grandfather passed from complications of pneumonia and Covid. Granddad (I called him Dad) was part of the men I considered my composite pops. He reached 89 years old, and yet his death seemed sudden. This past Christmas I brought Dad chicken and rice and we watched sports. Sure, he moved a little slow from living room to kitchen. Sure, he repeated a couple of questions and responses, but nothing I witnessed suggested he’d be dead in less than a month. And yet, less than a month later, family gathered at his bedside and, while Dad lay brain-dead on a ventilator, said their goodbyes. That same night, I awoke around 2:00 a.m. and, as I’d never done, began cleaning my house. Around 4:00 a.m. I said a teary-eyed prayer for my grandfather (Sam Jackson Jr.), thanked him for being a father to me, wished him heaven-bound, and mourned unbidden for the fact of its privacy.

What’s more doleful, mourning the dead or the living?

My grandfather left his youngest son as an executor of his estate and beneficiary of his retirement account. This is the same uncle who coached me into a track-and-field city champion, who spent umpteen hours helping me work on my hoop skills, who let me stay with him for a few months when my mother was deep in the throes of her addiction. Nonetheless, in the weeks after my granddad passed, the family discovered that my uncle (let’s call him A. J.) withdrew the funds from my granddad’s retirement account and kept most of the money to himself. Kept it regardless to his being but one of my grandfather’s four surviving children. Kept it despite two of his siblings being poor and disabled.

I don’t have to give anyone anything, he told us. A breach that has plunged me into what might be my profoundest grief. Because it’s a loss not grounded in the irrevocable. Because, given the natural order, I’ve lost my uncle once and will lose him again. Because how do I forgive the seeming unforgivable?

So here I am groping for what, in On Grief and Grieving, Kübler-Ross and David Kessler describe as the sixth stage—(finding) meaning—and meanwhile experiencing the stages I’ve beat back my whole life. The denial. The bargaining. The depression. Unc, not you. How could you? Don’t do this, Unc, please. It ain’t worth it. What do you need, Unc? Aren’t there other means? Unc, what about Dad’s desires? Unc, I don’t want to lose you, but what choice will this leave me? What if, Unc? What if? What if? Uncle, don’t you love us? In any case, I’m okay? I’ll be okay? I’m strong?

Complete Article ↪HERE↩!

October 11, 2023October 10, 2023

Inside The Festive Jazz Funerals Of New Orleans

By Richard Milner

When thinking of a funeral, many people might imagine a congregation of black-dressed folks staring at the ground while sad — perhaps with rain pattering on umbrellas for full, somber effect. But while sorrow itself is a natural response to the loss of life, funerals the world over often take on special flavors depending on culture, history, region, and so forth, some more lively or unusual than others. “Fantasy coffins” are all the rage in Ghana, shaped like lions, rockets, sneakers, Coke bottles, airplanes, you name it. Varanasi, India burns 24-7 funeral pyres to incinerate the dead before tossing their ashes into the Ganges river. Taiwan, meanwhile, has mafia-linked funeral strippers who dance and gyrate above coffins. And in New Orleans? It’s all about exuberance, joie de vivre, and music perfectly befitting them both: jazz.

In a way, nothing could suit New Orleans more than jazz funerals. A fusion of West African, British, Spanish, and French influences combined with Mardi Gras, Black Southern Protestantism, and the spirituals of enslaved Americans, jazz funerals are just as sui generis — a thing of its own — as New Orleans itself. As sites like Vox highlight, jazz funerals mourn the dead, but they also celebrate life and the hope of life after death for the one who’s passed away. Imagine a big, community brass band parade marching through the streets and you’ve got a good idea of what jazz funerals are like.

From the old world to the new

All sources point to New Orleans’ jazz funerals originating with indigenous, festive dance-and-music funeral processions in West African countries like Senegal and Gambia, as Vox explains. The Balch Institute for Ethnic Studies explains that ethnic groups like the Yoruba and Dahomean in the current-day nations of Benin and Togo have similar practices. Such practices revolve around celebrating the soul’s entry into the afterlife and connect to beliefs in the spirit world and a hierarchical cosmic order of God-spirit-human. This is why West African spiritual beliefs — when they arrived in the New World — ironically found a fitting home within predominantly Christian Americas.

Aeon, meanwhile, also cites cultural back-and-forth between New Orleans and nearby Caribbean nations like Haiti as helping give rise to jazz funerals. Notably, Haitian Vodou (also spelled “Voodoo”) retains celebratory practices meant to appease spirits. And of course, as French Quarter says, New Orleans has always been a hotspot for Louisiana Vodou for the same reason it spawned jazz funerals: slavery. From about 1480 C.E. to 1888 C.E., the Transatlantic Slave Trade took enslaved peoples from various African tribes to the Americas. Some of these individuals wound up in New Orleans, founded in 1718 by French-Canadian explorer Jean-Baptiste Le Moyne, Sieur de Bienville. From that point, New Orleans’ syncretic culture brewed.

Brass band, Mardi Gras, and spirituals

New Orleans’ founding as a French city added another critical piece to the jazz funeral puzzle: Mardi Gras, the French incarnation of the Catholic Lenten holiday of Shrove Tuesday, aka Fat Tuesday, the day before Ash Wednesday. As Father William Saunders says on Catholic Culture, Shrove Tuesday was the Catholic liturgical calendar’s” last chance for merriment” before showing restraint during Lent. Traditions date back to ancient Rome, connect to pagan holidays like Saturnalia, were documented by the Anglo-Saxon clergyman Abbot Aelfric in 1,000 C.E., and by the time we get to the founding of New Orleans in 1718 involved celebratory processions and parades down the street, as Mardi Gras New Orleans describes.

New Orleans, meanwhile, was passed to Spain in 1763. It soaked up Spanish culture for 40 years before the U.S. bought it as part of the Louisiana Purchase in 1803. Per Metro, it was common for military brass bands to play funerals during this entire time. Such bands played the same instruments wielded in jazz come the late 1890s, when BBC says the musical form evolved into its familiar, syncopated, up-tempo form. But the roots of jazz, much like jazz funerals, dated back to 1819, shortly after Louisiana became a state in 1812. Per the BBC, enslaved Americans congregated in New Orleans’ Congo Square on free days, where African tribal dances and rhythms fused with colonial influences, brass band instruments, and one final component: Christian spirituals.

When the Saints Go Jazzing On

As 64 Parishes says, the first recorded version of a jazz funeral was witnessed by architect Benjamin Latrobe in 1819. West African influences were plain and apparent from the get-go, as those enslaved people engaged in “ring shouts,” a kind of call-and-response rhythmic dance circle that spins counterclockwise. Funeralwise says that the Catholic church wasn’t too keen on these kinds of gatherings — ironically so, given jazz funeral’s processional, celebratory connection to Mardi Gras. Nevertheless, it fell to Southern Protestant Blacks to engage in “public performances to consolidate a sense of community,” as J. David Maxson writes in Southern Quarterly.

On that note, Visit New Orleans says that jazz funerals typically incorporated the old folk spirituals that passed around the U.S.’ Protestant South, like “Nearer my God to Thee” and “When the Saints Go Marching In.” These spirituals strengthened community and united ancient traditions with present beliefs in a hopeful way. Even modern-day jazz funeral bands like the famed Dirty Dozen Brass Band still focus on spirituals, as their 2004 album “Funeral for a Friend” shows. Song titles include classic spiritual adaptations like “Just a Closer Walk with Thee,” “What a Friend We Have in Jesus,” “Down by the Riverside,” “Amazing Grace,” “John the Revelator,” and more.

Joining the Second Line

After jazz funerals fused with late 19th-century, recognizably modern jazz, they marched unabated into the 20th century. Jazz swept the U.S. in the 1920s following the end of World War I but petered off in popularity in the 1930s because Americans started struggling for disposable income. But come the mid-20th century jazz funerals started becoming more widespread, in part because funerals themselves became more affordable. This was especially the case for well-known New Orleans locals — such as jazz musicians — who were honored with jazzy outros befitting their lives.

It was during this time that jazz funerals took on a standardized structure. Musicians played sad, somber, hymn-like tunes on the way to a cemetery, where a memorial service took place, and then played lively, celebratory music on the way back. This “second line,” as it was called, is the typically bouncy and exuberant part of the jazz funeral that gives it its signature flair, as seen above. Locals could join the procession on the way to the cemetery — provided they were respectful — but more than likely folks joined during the celebratory second half of the funeral. As Ausettua Amor Amenkum of New Orleans’ Tulane University recalls on Vox, “I come from the era when you’re in your house and you hear music and you go ‘Second line!’ and you run outside.”

Modern homecoming ceremonies

Jazz funerals exist to this day and have taken to incorporating other elements of Black American culture, like funk, hip-hop, and rap. Currently, jazz funerals are held not just for jazz musicians or prominent New Orleans personages but also for young people or other members of the local community who died suddenly or tragically. Interestingly, Alive Network says that the 1973 James Bond movie “Live and Let Die” played a significant role in letting the wider world know about jazz funerals. That’s also when the term “jazz funeral” took root. Nowadays, jazz funerals can be found around the U.S. and the entire globe. In 2015, for instance, Memphis hosted a jazz funeral for blues legend B.B. King.

The biggest and most prominent jazz funeral likely happened on August 29, 2006, in the wake of 2005’s Hurricane Katrina. In case readers need reminding, Katrina and its flooding devastated low-lying New Orleans and killed a total of 1,833 people across Louisiana, Mississippi, and Alabama. Funeralwise says that thousands attended the jazz funeral conducted in honor of Katrina’s dead in downtown New Orleans, where residents had stood stranded the year prior.

While not everyone gets a jazz funeral, those interested can hire musicians for the task via agencies like Alive Network, including travel to cities besides New Orleans. And yet, on Vox musician Stafford Agee says, “I never liked considering a funeral being a gig. I’m performing for somebody’s homegoing ceremony.”

Complete Article ↪HERE↩!

October 7, 2023October 6, 2023

A Compassionate Journey

— Advocates for Inclusive End-of-Life Options

By Jen Peeples

The journey towards the end of life is an inevitable part of our human experience. However, the circumstances surrounding this transition can be far from equal, particularly for marginalized communities. We had the opportunity to meet with Meagan Williams, a member of the Communications Team for many national campaigns, including in Minnesota. She connected us to the exploration of tireless efforts of organizations like Compassion & Choices, that are dedicated to advocating for expanded end-of-life options through education, outreach, and legislative change.

Williams expressed that their work serves as a beacon of hope for those directly affected by inequities from the system, while also striving to grant patients who request medical in aid death a greater autonomy and respect during their final moments.

Compassion & Choices is a prominent advocate in this space. They are relentlessly working to shed light on disparities in end-of-life care. Understanding that the path towards a compassionate and inclusive approach to end-of-life decisions begins with education and awareness. Through their outreach efforts, they aim to empower individuals and communities-especially those from marginalized backgrounds, by providing information and resources needed to make informed choices. We had the opportunity to sit-down with 4 amazing advocates of Compassion & Care. Their work is an expression of their passion. One to be known today and remembered tomorrow:

Osha Towers (they/them), a key figure in the LGBTQ+ Leadership Council, shared firsthand the shortcomings in LGBTQ+ end-of-life care during the trying times of the COVID-19 pandemic in 2020. Towers emphasized that there is deep discrimination that often arises from a profound lack of understanding and empathy– leading to distressing challenges such as misgendering, legal vulnerabilities, and the denial of chosen families.

When asked the purpose of their passion in this field, they shared, “I lost many loved ones throughout my community. Working within Black and brown LGBTQ+ healthcare– Yet advocacy work within end-of-life care specifically rose for me within the LGBTQ+ community when my coworker lost their long-time partner. Although this was someone, they had spent years caring for, their partner’s family did not honor their relationship or the queer life this person lived. So, they swooped in, took over, booted any level of queer community from the process, and buried them outside of reflecting on their whole identity.”

The fire behind the Council’s mission centers on priorities like inclusion by meeting the unique needs of LGBTQ+ individuals while driving institutional change. By engaging with diverse LGBTQ+ groups across the nation, Towers has developed a shared understanding of the importance of medical aid in dying, shaped by the community’s collective losses during the AIDS epidemic.

Now, the medical in aid dying has not always been accepted or approved by certain communities. However, a different intention and meaning was brought the platform by Dr. Joanne Roberts, a terminally ill physician, also initially held reservations about medical aid in dying laws. However, her personal journey and convictions have led her to recognize that such legislation can provide relief and rested assurance to suffering patients.

Dr. Roberts has a compelling mission to humanize this issue through the power of storytelling, emphasizing that death transcends political divides and dispels concerns about the misuse of aid-in-dying by citing data from states with extensive experience in its implementation. To hesitant lawmakers, Dr. Roberts gently reminds them that this is an individual choice, and no clinician should feel compelled to participate if it violates their moral principles.

Along with Dr. Roberts fight to appeal to legislation, Dr. Rebecca Thoman oversees legislative advocacy for Compassion & Choices in Minnesota and has been tirelessly working to advance the proposed End-of-Life Options Act. Though it faced setbacks in 2022, Dr. Thoman remains hopeful that it could see action in 2024.

Recognizing the importance of countering misinformation and creating a sense of urgency around the topic of death through peer testimonies, Dr. Thoman faithfully educates and leads other physicians on the infrequent use and strict oversight of aid-in-dying. This is all while respecting individual doctors’ moral right to opt out. Dr. Thoman understands that for lawmakers, bridging the gap between hypothetical concerns, the realities of clinical practice, and personal stories are keys to garnering their unrelentless support. If the legislation passes, Dr. Thoman believes it will bring solace through expanded end-of-life options for countless diverse individuals.

While also on the legislature end, we have attorney Phil Duran. Duran is known for his advocacy in LGBTQ+ rights in the approaches of medical aid in dying work with a unique perspective. He understands that arranging the plans one’s medical aid in death can offer a sense of peace; a sentiment shared by same-sex couples who were once denied the right to marry.

Through his work with Rainbow Health, Duran is actively expanding culturally competent care access for LGBTQ+ and aging communities through provider education and patient empowerment. He acknowledges that privilege often plays a role in determining the level of agency one has in making end-of-life decisions. Duran believes that by countering religious opposition and amplifying diverse stories, we can broaden the movement for compassionate end-of-life options.

While each advocate featured in this article brings their own expertise and experiences to the table, there are common threads that unite them in their pursuit of a more compassionate and equitable approach to end-of-life choices. Education, empowerment, and equity are at the heart of their endeavors. Despite their diverse backgrounds, they all share a profound understanding of the value of having options and autonomy when it comes to one’s own passing. Through their steadfast commitment to amplifying diverse voices and stories, driving policy changes, and expanding societal mindsets – these advocates serve as inspiring examples of the passion that fuels a movement toward greater compassion and care at life’s transitioning end.

Complete Article ↪HERE↩!

September 16, 2023September 15, 2023

How Advance Care Planning Neglects Black Americans

— Researchers are rethinking living wills and other ACP documents to ensure seriously ill patients get the care they want.

By Carina Storrs

When Kevin E. Taylor became a pastor 22 years ago, he never expected how often he’d have to help families make gut-wrenching decisions for a loved one who was very ill or about to die. The families in his predominantly Black church in New Jersey often didn’t have any written instructions, or conversations to recall, to help them know if their relative wanted — or didn’t want — certain types of medical treatment.

So Taylor started encouraging church members to ask their elders questions, such as if they would want to be kept on life support if they became sick and were unable to make decisions for themselves.

“Each time you have the conversation, you destigmatize it,” said Taylor, now the senior pastor at Unity Fellowship Church NewArk, a Christian church with about 120 regular members.

Taylor is part of an initiative led by Compassion & Choices, a nonprofit advocacy group that attempts to encourage more Black Americans to consider and document their medical wishes for the end of their lives.

End-of-life planning — also known as advance care planning, or ACP — usually requires a person to fill out legal documents that indicate the care they would want if they became unable to speak for themselves because of injury or illness. There are options to specify whether they would want life-sustaining care, even if it were unlikely to cure or improve their condition, or comfort care to manage pain, even if it hastened death. Medical groups have widely endorsed ACP, and public awareness campaigns have promoted the practice.

Yet research has found that many Americans — particularly Black Americans — have not bought into the promise of ACP. Advocates say such plans are especially important for Black Americans, who are more likely to experience racial discrimination and lower quality care throughout the health care system. Advance care planning, they say, could help patients understand their options and document their wishes, as well as reduce anxiety for family members.

However, the practice has also come under scrutiny in recent years as studies reveal that it might not actually help patients get the kind of care that they want at the end of life. It’s unclear whether those results are due to a failure of ACP itself, or due to research methods: Comparing the care that individuals said they want in the future with the care they actually received while dying is exceedingly difficult. And many studies that show the shortcomings of ACP look at predominantly White patients.

Still, researchers maintain that encouraging discussions about end-of-life care is important, while also acknowledging that ACP either needs improvement or an overhaul. “We should be looking for, OK, what else can we do other than advance care planning?” said Karen Bullock, a professor of social work at Boston College, who researches decision making and acceptance around ACP in Black communities. “Or can we do something different with advance care planning?”

Advanced care planning was first proposed in the U.S. in 1967 when the now-defunct Euthanasia Society of America advocated for the idea of a living will — a document that would allow a person to indicate that they wouldn’t want to be kept alive artificially if there were no reasonable chance of recovery. By 1985, most states had adopted living will laws that established standardized documents for patients, as well as protections for physicians who complied with patients’ wishes.

Over the last four decades, ACP has expanded to include a range of legal documents, called advance directives, for detailing one’s wishes for end-of-life care. In addition to do-not-resuscitate, or DNR, orders, patients can list treatments they would want and under which scenarios, as well as appoint a surrogate to make health care decisions for them. Health care facilities that receive Medicare or Medicaid reimbursement are required to ask patients about advance directives and provide relevant information. And in most states, doctors can record a patient’s end-of-life wishes in a form called a physician order for life-sustaining treatment. These documents require that patients talk with their physician about their wishes, which are then added to the patient chart, unlike advance directives, which usually consist of the patient filling out forms themselves without discussing them directly with their doctor.

Many people simply aren’t aware of ACP, or don’t fully understand it. And for Black individuals, that knowledge may be especially hard to come by.

But as far as who makes those plans, studies have shown a racial disparity: In a 2016 study of more than 2,000 adults, all of whom were over the age of 50, 44 percent of White participants had completed an advance directive compared with 24 percent of Black participants. Meanwhile, a 2021 analysis of nearly 10,000 older adults from a national survey on aging found that Black Americans were 57 percent less likely than White Americans to have a health care surrogate.

Many people simply aren’t aware of ACP, or don’t fully understand it. And for Black individuals, that knowledge may be especially hard to come by: Several studies have found that clinicians tend to avoid discussions with Black and other non-White patients about the care they want at the end of life because they feel uncomfortable broaching these conversations or unsure whether patients want to have them.

Other research has found Black Americans may be more hesitant to fill out documents because of a mistrust of the health care system — rooted in a long history of racist treatment. “It’s a direct, in my opinion, outcome from segregated health care systems,” said Bullock. “When we forced integration, integration didn’t mean equitable care.”

Religion can also be a major barrier to ACP. A large proportion of Black Americans are religious, and some say they are hesitant to engage in ACP because of the belief that God, rather than clinicians, will decide their fate. That’s one reason why programs like Compassion and Choices have looked to churches to make ACP more accessible. Numerous studies support the effectiveness of sharing health messages in church — from smoking cessation to heart health. “Black people tend to trust their faith leaders, and so if the church is saying this is a good thing to do, then we will be willing to try it,” Bullock said.

But in 2021, an article by palliative care doctors laid bare the growing evidence that ACP may be failing to deliver on the promise to get patients the end-of-life care they want, also known as goal-concordant care. The paper summarized the findings of numerous studies investigating the effectiveness of the practice and concluded that “despite the intrinsic logic of ACP, the evidence suggests it does not have the desired effect.”

For example, while some studies identified benefits such as increasing the likelihood of a patient dying in the place they desired and avoiding unwanted resuscitation, many found the opposite. One study found that seriously ill patients who prioritized comfort care in their advance directives spent just as many days in the hospital as patients who prioritized life-extending experiences. The authors of the 2021 summary paper suggested several reasons that goal-concordant care might not occur: Patients may request treatments that are not available, clinicians may not have access to the documentation, surrogates may override patients’ requests.

A pair of older studies suggested these issues might be especially pronounced for Black patients. They found that Black patients with cancer who had signed DNR orders were more likely to be resuscitated, for example. These studies have been held up as evidence that Black Americans receive less goal-concordant care. But Holly Prigerson, a researcher at Cornell University who oversaw the studies, noted that they investigated the care of Black participants who were resuscitated against their wishes, and in those cases, clinicians did not have access to their records.

In fact, one issue facing research on advance care planning is the fact that so many studies have focused on White patients, giving little insight into whether ACP helps Black patients. For example, in two recent studies on the subject, more than 90 percent of patients were White.

“It’s a direct, in my opinion, outcome from segregated health care systems,” said Bullock. “When we forced integration, integration didn’t mean equitable care.”

Many experts, including Prigerson, agree that it’s important to devise new approaches to assess goal-concordant care, which generally relies on what patients indicated in advance directives or what they told family members months or years before dying. But patients change their minds, and relatives may not understand or accept those wishes.

“It’s a very problematic thing to assess,” said Prigerson. “It’s not impossible, but there are so many issues with it.”

As for whether ACP can manage to improve end-of-life care specifically in areas where Black patients receive worse care — such as inferior pain management — experts, such as Bullock, note that studies have not really explored that question. But addressing other racial disparities is likely more critical than expanding ACP, including correcting physicians’ false beliefs about Black patients being less sensitive to pain, improving how physicians communicate with Black patients, and strengthening social supports for patients who want to enroll in hospice.

ACP “may be part of the solution, but it is not going to be sufficient,” said Robert M. Arnold, a University of Pittsburgh professor on palliative care and medical ethics, and one of the authors of the 2021 article that questioned the benefits of ACP.

Many of the shortcomings of ACP — from the low engagement rate to the unclear benefits — have prompted researchers and clinicians to think about how to overhaul the practice.

Efforts to make the practice more accessible have spanned creating easy-to-read versions, absent any legalese, and short, simple videos. A 2023 study found that one program that incorporated these elements, called PREPARE For Your Care, helped both White and Black adults with chronic medical conditions get goal-concordant care. The study stood out because it asked patients who were still able to communicate if they were getting the medical care they wanted in-the-moment, rather than waiting until after they died to evaluate goal-concordant care.

“That to me is incredibly important,” said Rebecca Sudore, a geriatrician and researcher at the University of California, San Francisco, who was the senior author of the study and helped develop PREPARE For Your Care. Sudore and her colleagues have proposed “real-time assessment from patients and their caregivers” to more accurately measure goal-concordant care .

“Sometimes it’s awkward,” Taylor said. “But it’s now awkward and informed.”

In the last few years, clinicians have become more aware that ACP should involve ongoing conversations and shared decision making between patients, clinicians, and surrogates, rather than just legal documents, said Ramona Rhodes, a geriatrician affiliated with the University of Arkansas for Medical Sciences.

Rhodes and her colleagues are leading a study to address whether certain types of ACP can promote engagement and improve care for Black patients. A group of older patients — half are Black and half are White — with serious illnesses at clinics across the South are receiving materials either for Respecting Choices, an ACP guide that focuses on conversations with patients and families, or Five Wishes, a short patient questionnaire and the most widely used advance directive in the U.S. The team hypothesizes that Respecting Choices will lead to greater participation among Black patients — and possibly more goal-concordant care, if it prepares patients and families to talk with clinicians about their wishes, Rhodes said.

When Taylor talks with church members about planning for end-of-life care, he said they often see the importance of it for the first time. And it usually convinces them to take action. “Sometimes it’s awkward,” he said. “But it’s now awkward and informed.”

Complete Article ↪HERE↩!

June 22, 2023June 21, 2023

How many dead moms will it take to stop America’s maternal mortality epidemic?

Midwife Angie Miller listens to the heart beat of a patient’s baby in their home on June 29, 2021.

By Alyssa Rosenberg

When sheriff’s deputies in Florida went to perform a welfare check last month on Tori Bowie, the Olympic runner, they made the saddest possible discovery. Bowie and her newborn daughter were dead. Though the full story of Bowie’s last days has yet to emerge, some details are clear: She had died in labor, suffering from eclampsia and respiratory distress.

These tragic events are an enraging reminder that the United States’ maternal mortality rate is the worst in the industrialized world. Black women are up to three times more likely to die during or after pregnancy than White women. Almost two-thirds of all these deaths could be prevented.

Expectant moms deserve more from their lawmakers, providers, public health groups and hospitals: more visits before and after pregnancy, better access to the simple drugs and devices that could keep them alive, and expanded insurance coverage.

Since the federal government began keeping records in 1987, America’s maternal mortality rate has only gotten worse. Between 2000 and 2020, the United States was one of eight countries where the situation deteriorated fastest, a list that included Venezuela and Mauritius. There’s no one cause of this long slide: A strained health-care system, a stingy insurance system, a lack of paid leave, the retreat of reproductive rights and endemic racism all contribute.

Covid-19 made a bad situation worse. Pregnant women who contracted the virus were seven times more likely to die than those who avoided infection. But even as vaccination became widespread, pregnant women kept dying from all the more common causes: infections, hemorrhages, hypertensive disorders such as preeclampsia and embolisms. In 2022, 733 American women died while pregnant or shortly after childbirth. That’s a maternal death rate of 20 per 100,000 births — up from 17.6 in 2019, already two or three times the rate of many high-income nations.

For Black women, pregnancy and childbirth bring the toll of racism in the United States into sharp focus. A large body of research shows that being Black in America wears on women’s bodies, leaving them uniquely vulnerable during pregnancy. Black women are 60 percent more likely than White women to experience preeclampsia, for instance. Add to which they experience inequalities in access, quality of care, prescribing, data collection and more. These differences persist even among wealthy, educated women. So stark is the disparity it has come under United Nations scrutiny.

There’s much providers can do to help: A 2019 analysis of preventable maternal deaths by the Centers for Disease Control and Prevention gives a clear list. Open earlier or stay open later to serve patients who work nights. Accept Medicaid. Educate patients early and often about conditions to watch out for. Take patients with headaches or shortness of breath seriously.

And there’s a lot policymakers must do to keep pregnant women safe and healthy. Fortunately, even in this divided, fractious Congress, there’s bipartisan support. Bills introduced by Reps. Lauren Underwood (D-Ill.), Robin L. Kelly (D-Ill.) and Robert E. Latta (R-Ohio) and Sens. Charles E. Grassley (R-Iowa) and Maggie Hassan Wood (D-N.H.) would pull together working groups to identify the best ways forward. One target of Kelly and Latta’s: Finding ways to identify and improve hospitals and doctors who are failing women and babies.

Lawmakers in both parties agree that childbirth and postpartum support from other practitioners matters, too. Evidence is accumulating that access to doula care during labor can lower Caesarean section rates. Doulas offer mothers nonmedical support and advocacy before, during and after delivery. Programs run both by community groups and insurance giants are exploring whether doulas can have a measurable impact on maternal mortality, especially for Black women.

Congress funded some home health visiting programs in the 2022 government appropriations bill. The United States should join other wealthy countries in making sure new mothers get regular visits after they come home from the hospital, when they are still at risk.

It would also help to standardize how Medicaid covers the medicines and devices for pregnant people. An analysis by KFF found glaring gaps. Four state Medicaid programs still don’t cover low-dose aspirin, which can prevent preeclampsia. Ten don’t cover blood pressure monitors for use at home between doctor’s visits. And six states don’t cover glucose monitors, crucial for managing gestational diabetes.

Meanwhile, the federal government could kick-start pilot programs that explore new ways to lower maternal mortality. Examples include payment schemes that compensate providers who do a better job for mothers and babies or demonstration projects that bundle housing and prenatal care in the same setting.

We don’t know whether Tori Bowie and her baby could have been saved with earlier intervention. We do know how to save hundreds of other American mothers.

Complete Article ↪HERE↩!

March 26, 2023March 26, 2023

The Imposition of Black Grief

— Prolonged grief is normal—and even necessary.

By Nneka M. Okona

When the pandemic dawned on our shores in early 2020, I neither panicked nor despaired. There was something eerily familiar about how quiet and still the world suddenly felt—how we were all living in a groundless, uncertain reality.

I’d had countless experiences with personal losses in recent years, so I knew how isolating grief could feel. Though this time, we were all sitting in a darkened room, the heaviness of loss wrapped around us like a cloak and bonding us together in more ways than one.

Over time, we’ve developed the language to describe this shared experience—collective grief. This mourning is neither an individual expression nor an experience, but can be felt as an entity that impacts a group of people all at once. For Black people, collective grief has a particular shape, feeling, and shade.

Three Black people embrace while overlooking the silver casket of Conrad Coleman Jr., which is sitting above the burial plot, adorned with flowers. — Friends and family attend Conrad Coleman Jr.’s burial service in Rye, New York. Early in the pandemic, Black Americans were not only disproportionately more likely to contract COVID-19, but also more likely to lose a family member or friend to the disease.

For Black people in the United States, grief and loss are intertwined with our very being. Our ancestors knew the trauma of loss intimately; many of us, myself included, are descendants of those enslaved. The institution of chattel slavery throughout this country—not just in the Southern states—depended upon breaking up families in order to use our Black bodies for labor. We lost so much then. Though we’re generations removed from it now, those losses remain within us, embedded in our consciousness and our psyche, lying dormant in our bodies.

As a result, Black people have experienced the pandemic differently, beginning with the fact that we were disproportionately impacted by this deadly virus. And we have grieved deeply as a result. I released my debut book, Self-Care for Grief, on Aug. 3, 2021. I began writing it in September 2020 when life still felt uncertain, but I wanted to give readers a soft place to land as they grieved. I wanted to remind people that they can grieve in their own way and that there aren’t any rules for how that should look. But that was hard to do knowing the state of the world outside my front door. The seasons were changing, which meant another spike in COVID-19 cases, hospitalizations, and deaths. The hope of a vaccine seemed like a pipe dream at best.

While official messaging encouraged everyone to continue being cautious, many Black people knew this to mean that, once again, we had to save ourselves. Misinformation was high. There wasn’t consistent or accurate reporting about how many people had contracted COVID-19. Guidance on how to protect ourselves—with masks, wiping down groceries, keeping a 6-foot distance—varied depending on the day. We had to bind together to get through, something Black people have always done. If we were going to survive, we needed to grieve, process, and make meaning of our losses. We inherently knew these things, even if many of us couldn’t recognize them at the time.

Grief requires tenderness. Demands it, even. As Black people, being rough or careless with our grief is more of the same indoctrination from Western culture and society. Trying to survive in this capitalistic society teaches us that we should not value stillness or rest. And racism always gives us a reason to be aggrieved and to fight for our humanity to be acknowledged and validated. Honoring our losses—and the grief that follows—means bowing to stillness. It then becomes necessary to have the courage to look at our grief and recognize it for what it is—not a nuisance to be gotten over as quickly as possible, but a force that will forever change us. Grief calls us to bend, to evolve, to integrate the losses that we’re reeling from.

Loss encompasses more than the death of a loved one. We may need to grieve former states of being, old routines, a neighborhood or city we moved away from, a dream we have outgrown or had to let go of, a sense of safety or inner peace, or the end of a relationship with someone who is still alive. The list is nearly as endless as the ways that we can honor our grief.

Marcia Howard, a community member and activist in Minneapolis, Minnesota, straightens mock tombstones in November 2022 in the Say Their Names Cemetery, an art installation that sits in a grassy park one block north of the George Floyd Memorial. Names visible on the tombstones include Philando Castile, George Floyd, Tank Blanding, and more. — Marcia Howard, a community member and activist in Minneapolis, Minnesota, straightens tombstones in November 2022 in the Say Their Names Cemetery, an art installation that sits one block north of the George Floyd memorial. The installation began with 100 names of Black lives cut short by police violence, and grew as the community requested more to add.

A Black Story of Grief

In modern times, there are new things to grieve. Rather than only hearing about the violence of white-supremacist police brutality on news stations or seeing it splattered on the front page of the newspaper each morning, we have the ability to witness it happening in real time via social media. We now have more awareness and more investment in taking a stand against racial injustice, but seeing these old wounds with even older origins so often, so graphically, comes at a cost.

The murder of George Floyd in Minneapolis on the evening of May 25, 2020, was a catalyst for the anger bubbling underneath the surface for most Black Americans to emerge with power and force. We were so tired of soldiering on even when little losses constantly surrounded us; of having to be OK with the unwarranted deaths of our brothers, sisters, cousins, aunts, uncles, mothers, and fathers. We were so tired that “tired” no longer sufficed; we needed another word to encapsulate the full breadth of all it means to hold, all it means to live as a Black person. We wanted to feel safe and to not fall prey to the potential lethality of driving while Black, walking while Black, eating while Black, traveling while Black.

We wanted Blackness in this country to stop equating to a death sentence.

Living with this knowledge is not only heavy but tortuous. It impacts mental health, the ability to build and maintain interpersonal relationships, holding onto employment and performing well. As much as one might think it’s possible to compartmentalize how structural and systemic racism affects Black people, that’s not the case. Robert T. Carter, professor emeritus of psychology and education at Teachers College of Columbia University, pioneered research on the relationship between racial trauma and mental health.

In a 2007 study, Carter found that, as a result of racial discrimination, Black people can develop racial trauma profound enough to be considered a psychological trauma comparable to PTSD, according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). “Racism can and does create damage to one’s psyche and personality in the same way that being subjected to community violence, being held captive, or being psychologically tortured can create emotional damage,” Carter writes.

Though Carter was one of the first to codify the mental health impacts of racism, five years earlier, psychiatrist and psychoanalyst Hugh F. Butts used the term “racial trauma” to ground further research, study, and understanding in the topic. In a 2002 article, Butts notes that “responses to racial discrimination by African-Americans are often not viewed as severe enough to indicate that these blacks may have post-traumatic stress disorder.”

PTSD from racial trauma can cause hypervigilance, depression, anxiety, and chronic stress, which forces our nervous systems to roar into overdrive.

And yet, more than two decades later, it’s reported that 71% of Black Americans experience some form of racial discrimination in their lives. This number seems low, especially considering how racial trauma actively changes us and the way we live. PTSD from racial trauma can cause hypervigilance, depression, anxiety, and chronic stress, which forces our nervous systems to roar into overdrive. New research from the University of Arizona takes this one step further. In a study published in April 2022, researchers Da’Mere T. Wilson and Mary-Frances O’Connor explored grief and bereavement implicit in the racial trauma Black people live with.

Wilson and O’Connor assert that solely associating grief with the loss of a loved one makes the definition “too narrow in scope.” Per the study, “This lack of representation, plus the prevalent universalist research framework in psychology, has led to a lack of understanding of how the specific contextual factors of living as a Black person, in a Western country like the United States, may differentially impact the experience of grief.” Like Carter, the two also research how grief and loss can catalyze political and social action. They illustrate that the racial trauma, grief, loss, and bereavement that follow are interconnected in an interdependent web.

So, how can we care for ourselves in a world that doesn’t recognize our pain and suffering—and doesn’t want us to be well?

A day after the hate crime and mass shooting at Tops Market, Latisha Rogers is comforted by the community and support of True Bethel Baptist Church in Buffalo, New York, on Sunday, May 15, 2022. Rogers, a Tops assistant office manager, was not only present at the mass shooting, but she called 911 to report the gunman, only to be admonished by the operator for whispering.

How We Rebuild

Black Americans have created moving rituals to help us honor and process those losses. We are a communal people. The strength of the village, not just the heteronormative and very white nuclear family model, is what we lean upon.

When someone dies, Black Americans gather at funeral homes, at churches, at banquet halls. We gather in love. We cry, we eat, we honor their lives. Yet, during much of the pandemic, these beautiful grief rituals have been disrupted. Instead we had to grieve alone in our homes, isolated from our communities, behind a computer screen. Zoom funerals became the norm, shaky cell phones and iPads capturing our grief in unprecedented ways. Within the grief space, there are Black folks meeting the evolving needs of their communities. Breathworker and grief guide Naomi Edmondson lost her grandmother, whom she considered a mother figure, in 2019. “When I lost her, in a way I lost the center of my universe,” she says. “Then having to handle that loss with COVID and the grief surrounding the pandemic, there were so many layers of grief that I was dealing with.”

As a result, Edmondson created a virtual space called Black Folks Grieve as a safe container for both herself and others who look like her to discuss their losses and grief. Every Monday evening, she facilitates a sharing circle for anyone who signs up via her website. “Before I started the group, I was looking for places where I could be in and not only feel like my grief was validated, but I didn’t have to do this intense labor to explain myself,” she says. “The last thing you want to have to do is the work of trying to make someone understand where you’re coming from.”

Fellow grief guide Alica Forneret came into the grief space after unexpectedly losing her mother in October 2016. Submerged in grief, Forneret channeled all she was feeling into Instagram missives about every aspect of grief. She also began consulting with companies on bereavement policies designed to make it easier for employees to cope with grief in the workplace. “How people treat you and your pain, the processing of pain, and your vocalization of that pain, I have found is the most interesting to talk to people about,” Forneret says. “The difference between me showing up to work every day in June of last year and everyone else is very different. The way that we are supported and need care is very different too.”

Now, she sees her work evolving. She’s working on her first book and is building a nonprofit called Pause that will help Black people formalize (and, in some cases, professionalize) their grief work to support those who need it most. Edmondson and Forneret are part of a legion of Black people—many of them Black women—revolutionizing how grief can be tended to. There’s Oceana Sawyer, a former transition guide, who uses Patreon to offer conversations and grief circles about honoring death as a rite of passage. She went from talking about grief on an individual level, before summer 2020, to now talking about collective grief.

She says she started looking at Resmaa Menakem’s work on somatic abolitionism and applying it to grief. “That led me to a deep exploration around how bodies, specifically bodies of the African Diaspora, are metabolizing grief alongside all the other losses that we incur on a daily basis.” This newfound curiosity fueled an expansion of Sawyer’s offerings: In addition to the virtual death cafes she’s led for Black and Brown people, she’s also hosted joy-mapping workshops on Afrofuturism, womanism, the end of the world, and more.

In the realm of academia, Kami Fletcher, associate professor of American and African American history at Albright College, refers to herself as a death scholar. She found her way into death studies during graduate school when her chair told her about an opportunity to act as a researcher for Mount Auburn Cemetery, Baltimore’s oldest African American burial ground. She spent years researching and writing about Mount Auburn and says, “It helped me to learn a lot about cemeteries, the records [that] this space keeps, and what that means to people who are supposed to be invisible in history.”

“I don’t think I realized that folks were using death studies—death, dying, bereavement, and grief—to mobilize and organize in really interesting ways,” she says. In 2018, she co-founded the nonprofit Collective for Radical Death Studies with the implicit aim to decolonize death studies and radicalize death practice. Death work, the Collective’s website states, is anti-racism work. It provides resources and information on death studies, death practices, and deathways, such as the Radical Death Studies Canon, which spans topics ranging from queer death and capitalism to colonialism and genocide. “Our mission is to decolonize death studies, and for us [that] really means to decenter whiteness,” Fletcher says.

There’s also author and end-of-life caregiver Breeshia Wade, who recently penned Grieving While Black: An Antiracist Take on Oppression and Sorrow, about living with racial trauma. And Sundari Malcolm, who hosts the BIPOC Dinner Party, an organization created with the goal of bringing people around (virtual) tables to talk about grief. Of course, there are countless others. The wide-ranging approaches to facing our grief and sitting with it, according to Forneret, is truly something to behold. It’s also something that gives her hope. “The diversity of people doing this work, the different ways they approach their work, and the complexities are so different and deep,” Forneret says. “It feels so rooted. And that’s why I want to support the people in our community.”

Complete Article ↪HERE↩!

March 14, 2023March 13, 2023

Rise in infant deaths hits Black families hardest, study finds

Black babies experienced the highest rate of sudden unexpected deaths in 2020 and nearly three times the rate of deaths among White babies.

BY Frances Stead Sellers

A new federal study highlights a striking racial disparity in infant deaths: Black babies experienced the highest rate of sudden unexpected deaths in 2020, dying at almost three times the rate of White infants.

The findings were part of research released Monday by the Centers for Disease Control and Prevention, which also found a 15 percent increase in sudden infant deaths among babies of all races from 2019 to 2020, making SIDS the third leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth.

“In minority communities, the rates are going in the wrong direction,” said Scott Krugman, vice chair of the department of pediatrics and an expert on SIDS at Sinai Hospital in Baltimore.

The study found that rising SIDS rates in 2020 was likely attributable to diagnostic shifting — or reclassifying the cause of death. The causes of the rise in sleep-related deaths of Black infants remain unclear but it coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities.

“Evidence does not support direct or indirect effects of the … pandemic on increased rates of sudden unexpected infant death, except for non-Hispanic Black infants,” said the study, to be published in the April issue of the journal Pediatrics.

The study’s authors, who call for further research into their findings, point out that the pandemic exacerbated overcrowded housing, food insecurity and other stressors, particularly among Black families — potentially leading to less safe sleeping practices, such as bed sharing.

Before the pandemic, overall infant mortality — including diseases, accidents and injuries, and unexplained deaths — had been on a downward trend in the United States. Some of that drop can be attributed to the enormously successful campaign launched in the 1990s to encourage putting babies to sleep on their backs, as opposed to facedown when they may re-breathe the carbon dioxide they exhaled or suffocate in soft bedding.

Tracking and understanding the causes of sudden and unexpected infant deaths on a national scale has been challenging in part because of different local practices of reporting and investigating the deaths. Data based on death certificates is notoriously inaccurate, and the pandemic introduced further complications, including shortening the time overburdened examiners could devote to investigating individual deaths.

The CDC’s Division of Reproductive Health has tried to address those problems by setting up monitoring programs in 22 states and jurisdictions across the country and by working with medical examiners and coroners to standardize reporting procedures. The new study draws on that research.

“This study is using good quality data, putting what some of us have been doing on a local basis on a national scale,” Krugman said.

In addition, a shift in terminology has complicated the picture. SIDS, or crib death, refers to the sudden death of an infant under the age of 1, usually during sleep and for unknown reasons, though often related to suspected genetic or environmental factors.

That term has fallen out of favor among some medical examiners and coroners who have replaced it with the broader term SUID, or sudden unexpected infant death under the age of 1. SUID refers to the often sleep-related deaths of babies in which the causes include suffocation from being caught between cushions of a couch or strangulation beneath a sleeping parent as well as SIDS and other unknown causes. About half of SUID deaths are SIDS deaths.

>“It’s a terrible situation,” said Richard Goldstein, director of the Robert’s Program on Sudden Unexpected Death in Pediatrics at Boston Children’s Hospital. “There is so much inconsistency in what these deaths are called. That’s not tolerated in any other area of medicine.”

On average, about 3,400 U.S. babies die suddenly and unexpectedly each year, according to CDC data.

To examine racial disparities, researchers chose to use the overall SUID rate, which allowed for consistent comparisons that were not affected by the different ways medical examiners report infant deaths.

In 2020, the SUID rate was highest among Black infants (at 214 deaths per 100,000 live births), followed by American Indian or Alaskan Native infants (at 205 deaths per 100,000 live births), and nearly three times the rate for White infants (75.6 deaths per 100,000 live births).

Understanding the causes of those deaths, many of which are unobserved, is key to preventing them.

“We don’t know how to prevent SIDS,” said Michael Goodstein, a neonatologist at York Hospital in Pennsylvania, who said research is examining factors such as brainstem abnormalities and respiratory problems. “But we should be able to prevent suffocation deaths.”

Sharyn Parks, one of the study’s authors and a senior scientist at the CDC’s Division of Reproductive Health, said there are two clear messages to take from the study — the need for researchers to examine factors like poverty that make some families more vulnerable to poor health outcomes as well as the need for parents to remember the practical steps they can take.

“We want to continue emphasizing safe infant sleep practices, putting babies on their backs and removing all soft bedding,” Parks said.

Once it is available, data from 2021 and 2022 should provide a clearer sense of the role the pandemic may have played in widening disparities between different racial groups.

“We are getting more and more a sense that poverty and multi-factorial issues are really important for being able to protect children,” Goodstein said.

Complete Article ↪HERE↩!