An Analysis of the System is Protective: An Interview with Scott Nappalos

Scott Nappalos is a health care worker in California.  We asked him for an interview because we thought that he would be able to provide some insights into the realities and challenges of health and health care work  in the present moment that went beyond the superficial.

We’d like to start by asking you to talk about the work you do and the patients you care for.

I’m an adult primary care nurse practitioner. Throughout my entire career as both a nurse and nurse practitioner, I’ve worked in “safety net” institutions which are either public or partially publicly funded healthcare hospitals, clinics, and centers that serve people who generally lack resources to access medical care via the health care market. During the pandemic and for many years prior, I have worked in community health centers which are federally funded to provide primary care to the uninsured and under-insured. (Currently I’m in the central coast of California). Community health centers in states that expanded Medicaid under the Affordable Care Act serve the bulk of their patients through Medicaid because essentially all major health institutions refuse to see these patients as the reimbursements are too low. In essence, I function as what in another era would have been a family doctor, but today is split between nurse practitioners, physicians, and physician’s assistants. My patients are largely working class and poor, disproportionately people of color, and often exist on the razor thin line between employment, housing, health, and safety and disability, homelessness, deportation, violence, and prison.

Can you say something about the different thoughts and feelings that patients have about health care?

First, it should be said that many people I care for had little to no access to health care for much of their lives until the public system was expanded. When they were seeing me as the first primary care provider in their adult lives, I have had countless people tell me about simple, preventable conditions that created a downward spiral of poverty and disability simply due to lack of access to care. Many had little or no experience with the health system until they received Medicaid and view things through that lens. Others have had private insurance intermittently when they had jobs that offered it. In general, I think there is widespread fear out there. People are scared that the health system will harm them, which is not unfounded sadly due to a variety of factors that makes unintentional harm a persistent problem in the industry. They fear being diagnosed with something that is crippling or expensive and that they will lose access. There is a sense that someone is always trying to screw them and that the system works well for some but rarely them. It is rare unfortunately, but some people do have a broader awareness of the situation and can be thankful for the care they receive in spite of the challenges. It’s a side point, but those who are able to access expanded Medicaid don’t get everything they deserve, but they do get a fairly high standard of care. If you look at places like the west coast you actually see health metrics similar to other success stories around the world. The US overall tends to be very regionalized and stratified across its territory by health and, of course, class.

It should also be said that the undocumented as a whole in my experience are consistently the most grateful for the care they receive and the most diligent for reasons you could imagine, in reality to a fault because they and all of us deserve so much more.

What have been the reactions among your patients to the COVID pandemic broadly understood–the spread of the virus, the restrictions placed on some people and the demands placed on others, the symptoms that infected people have had, the testing, and most recently the vaccines?

My interactions are skewed because the hardline conspiracy theory or western medicine skeptic patients often will avoid interactions with health care professionals unless they’re trying to get things they can’t easily obtain otherwise. Occasionally I do get people requesting treatments they have read about on conspiracy sites and those interactions are generally short and semi-hostile. Generally, people have what you might expect which is an understanding of the virus and the epidemic drawn from a mix of traditional media, personal connections, and social media sources of dubious value. However, if someone comes to you as a health professional, it’s usually because they actually do want to know what you think and will take that in as a data point with some impact alongside the other places they draw from. Early on, there was broad skepticism and many definitely had a cavalier attitude of it being just a minor cold, which it isn’t of course, or saying things like “I/my friend had it and they had no symptoms”. You gradually saw the death and debility roll through broad swaths of the public so that once it had touched people closer to home there often, but not always, was an attitude change about the seriousness of the virus. Most people follow good practices of masking and hygiene where that infrastructure is in place, and more or less follow the county’s policies where I live due to social pressures since compliance here is pretty good, and even better in nearby counties like the Bay Area. When those rules or practices aren’t in place however, patients just return to prior social norms largely. There has been some resistance to testing because people fear loss of work and their employers threaten them. I had a case where an employer was asking his employees to use home COVID tests instead of going through a medical facility. The idea was that the home tests would not be reported to the county health department and that way he could keep the business going with positive cases, seemingly in cooperation with COVID skeptical staff in an area with lots of allopathic (conventional or mainstream) medicine skeptics. We found out because a worker was exposed to COVID via a positive co-worker and this person did take the disease seriously. Yet again often you’re not going to run into those kinds of folks except if they want something from you like a “return to work” letter, clearance to fly, fad treatments they need a script for, etc.

Vaccines are their own thing. I’ll address that below.

What are you most interested in finding out when you talk to patients?  Have there been any surprises?

Honestly just on a personal level, I love to hear people’s stories and that has been something that’s kept me happy in the job as long as I’ve done it. It feels like a real privilege to get a window into thousands (tens of thousands?) of people’s lives. You really grow and learn, let alone stay grounded, when that is a consistent part of your life.

Aside from that I also have a real drive to understand the broad context of illness in a way that excites me. If you end up diagnosing something that whole slews of people missed for decades it’s kind of addicting. The medical mystery element is something I enjoy in that way and all that entails: family history, how the illness emerged, changed, what effects it has had, etc.

Something I hadn’t anticipated was how close I’d get to suffering in a way, or at least not in how I had imagined it. I’ll give one example. When it comes to violence we often think about the event, what precipitated it, and maybe like ongoing injuries or PTSD. Being a primary care provider has brought me close to violence in that I see all the resonant effects from the perpetrators, the survivors, and even just people related to any people involved. Those are sometimes deep and long lasting and lead to things like chronic disease, drugs, further violence, imprisonment. That closeness has changed my view of the world and amongst other things violence and poverty in a sense, even as a revolutionary. I guess you could say I feel more guarded and cautious about life and people, how fragile everything is. Things like that are what grab my interest.

We assume that some of your patients have been reluctant to get vaccinated.  Are we right?  Can you tell us about their views and the experiences that inform them?

First a majority of people in California and the broad Northern California area have been vaccinated. Hardline anti-vaccine people are definitely a small but significant minority with a disproportionate influence. Yet there is widespread fear not of vaccines overall, but a semi-incoherent fear of various vaccines. Those fears are not uniform either, and we can look up the data on which communities are more affected. Before all this I’d get a lot of pushback on the flu vaccine, but rarely against pneumonia, shingles (“I saw that on TV, it looks terrible!”), or tetanus vaccines.

It’s similar now where people are just fearful that someone is trying to experiment on them, control, or profit from them and don’t know who to trust. I get a lot of questions about misinformation running around that they make you sterile, change your DNA, let alone the wacky stuff like magnetism or the government injecting chips into you. Often if I address someone’s specific concerns, they are polite and sometimes change their mind. There’s a surreal seasonality about all the misinformation. For a while people started freaking out about the pertussis or whooping cough aspect of the TDAP (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) shot which is a new phenomenon, but then that sort of fell off the radar. Today in fact, I was literally berated and screamed at by an anti-vaccine person demanding an inappropriate medical exemption pre-emptively for the COVID vaccine, but the person finished it all off by being angry that another vaccine was not offered to her in a context where she was likely to contract a different disease.

The experiential background to all this of course would include all the historic wrongs committed against women, people of color, queers, and the working class broadly that damaged the relationship between health care and the public. Likewise, the excesses of capital with many noticeable slip ups along the years in terms of medication safety, health care caused injuries in hospitalization, and arrogance that led to people continually being disregarded and ignored are definitely in the minds of many. I would say that those fears are fairly general and lacking the details because we miss the real advances that the US has in terms of science and safety which were won through struggle, and those gains are being eroded gradually without much resistance. I blame the lack of consistent movements both of patients and workers that could be putting out that alternative and facilitating that dialogue.

Are there any noticeable differences in the attitudes of men and women or of younger and older people?

Strangely there is some evidence from a bit ago that younger mothers are more vaccine skeptical vs fathers which is interesting, but is probably in line with cultural norms in some ways. Where I am, the elderly overwhelmingly embraced the vaccine, but young people have always been more challenging (they access care less and are less economically/insurance secure).

Do you have any suggestions for people who’d like to talk with others about the issues and realities?

Of the vaccine? I actually personally am quite cautious about essentially all treatments in that I like to see good evidence before I recommend something. That said, everything depends on the available alternatives, what has been tried, and the risks. If you face terminal rapidly spreading cancer, experimental treatments may be justified depending on your goals because the risk is so great. With COVID the dangers are quite high even if there’s no death, hospitalization is concerning, and we don’t really know but there may be lasting health effects that are post-infectious making anything that can prevent any of those series of events desirable. Whatever concerns people have about the vaccine should be weighed against that. Moreover, we actually have much more data than normal given how widespread vaccination has been which is likewise reassuring.

Do you have any ideas about how health care workers could be better prepared for dealing with the complexities involved?

First, I would argue there’s been a collapse of confidence and coherence in the public health system in the US. This is largely political, but also reflects a broad loss of faith in authority in the US as the ruling class has fragmented over prior decades, social institutions have frayed, and no real popular alternative has emerged to provide a cohesive pro-social force. Health workers in the US have always needed to come together and put forward a vision of social health, resist the elements that have bled the industry, and take on fights for the benefit both of workers and patients. That is a long way off sadly but even the first steps are needed.

I have always thought additionally that having an analysis of the system, capitalism, and the state is protective in health care. If you’re not prepared for how dark things can get, it can overwhelm you and you likely miss a lot of the beautiful aspects of humanity that are out there. Burnout is severe and pervasive, and I do think that contextualizing it all doesn’t stop that from happening but it can help you navigate it. Beyond organizing and having a greater understanding, ultimately we need to take care of ourselves and each other similarly to how an athlete trains. The chronic stress, attacks, and danger of the job takes a toll so we all need to do simple things (like what we tell our patients) like exercise, mindfulness, regular breaks, avoid over-working if possible, sustain healthy and robust relationships, and take care of each other.

Any other thoughts?

It’s been such a slog and there’s been so much put on our plates this last stretch, it really is the time to bring people together and do the hard work of fighting to make things better as well as formulate an alternative vision from within health care. No one is doing that work on a consistent basis from a liberatory perspective. Every day that absence is clearer and its effects more serious.

 

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