Veronica Santana-Ufret

Honors 231, Dr. Victoria Lawson

March 9, 2015
I did my service learning at Harborview Medical Center (HMC), a local hospital that
provides health related services to various vulnerable populations. Volunteering at HMC has
been an eye opening experience. Looking at HMC through a care ethical lens has given me a
richer understanding of the class material. This class has helped me learn new ways to analyze
and understand social issues such as poverty. Volunteering at HMC has given me the opportunity
to practice these methods of analysis. The work we have done this quarter has provided me with
a strong foundation for future learning about social justice issues.
Harborview Medical Center is owned by King County, governed by the Harborview
Board of Trustees, and run under contract by the University of Washington. It began as King
Countys welfare hospital, a six-bed two-story facility in South Seattle. In 1931 it moved to the
building in which it currently resides. Today, HMC is a well-recognized patient care facility that
is also very involved in teaching and research. Harborview has many well-known programs.
These programs include: the largest burn center in the country, one of the few AIDS research
programs, a clinic that is the largest single provider of AIDS care in King county, and the Center
for Sexual Assault and Traumatic Stress, to name a few. HMCs primary mission is, to provide
and teach exemplary patent care and to provide health care for those patients King County is
obligated to serve (2015). Harborview is especially responsible for caring for people
incarcerated in the King County Jail, mentally ill patients, immigrants, victims of domestic
violence, victims of sexual assault, and the poor. I volunteered in the Patient and Family Liaison
Department at HMC to complete this classs service learning requirement. As a volunteer I was
expected to assist patients and visitors of HMC by providing non-medical support. I was
frequently asked to respond to visitor questions and concerns, manage wait rooms, provide

information on places to stay and introduce patients and visitors to hospital and community
resources. I also provided special services to patients and families, such as hospitality visits and
provision of items for entertainment.
There are various social phenomena that give rise to the need for care that Harborview
addresses. One such phenomenon is the development of Seattle into a metropolitan city with a
diverse population and a constant influx of immigrants. Massey argues that, a real recognition
of the relationality of space points to a politics of connectivity and a politics whose relation to
globalization will vary dramatically from place to place (2004). Seattle is one such place that
has been dramatically influenced by globalization. Seattle is, in part, defined by its industries,
such as Boeing, Microsoft and Amazon. These industries attract people from all over the world.
Seattle is also a product of its physical location on the West Coast, a location that makes it an
entry point into the United States for many people from Africa and Asia. Seattles identity is
largely a product of relations which spread out way beyond it (Massey, 2004). This identity
produces a need for healthcare facilities that have the infrastructure to serve people of many
different nations, religions, languages, and cultures.
Another phenomenon that has contributed to the need for the care that Harborview has
been the privatization of care. HMC is the only publicly funded level 1 trauma center serving
Alaska, Washington, Idaho, and Montana. I believe that this fact is evidence of, the off-loading
of medical treatment for both acute and chronic conditions from hospital to homes (NakanoGlenn, 2012). This off-loading has shifted much of the burden of care from the public sphere to
the private sphere. The privatization of care has been one of the impacts of the neoliberal
movement. Neoliberalism holds that free-market economics is, necessary and sufficient for the
creation of wealth and therefore for the improved well-being of the population at large (Harvey,

2005). Under a neoliberal framework the market and those that participate in the market are
prioritized. The shift from institutionalized health care to home care has been, part of a larger
strategy to transfer work from paid employees to consumers, thereby reducing costs and
maximizing profits (Nakano-Glenn, 2012). This shift has placed a huge burden on the few
publicly funded medical institutions; HMC is constantly overflowing with patients. Healthcare
has become so burdensome and expensive, that places like Harborview are needed to catch the
people who would otherwise fall through the cracks of our current healthcare system. These
people include critically ill individuals who dont have the money or whose families dont have
the time or inclination to care for them. Neoliberalism has also led to a dramatic increase in
social inequality (Harvey, 2005). The US currently has one of the largest income differences
among developed countries, putting it among the most unequal countries globally (Wilkinson &
Pickett, 2010). The immense disparity between rich and poor has increased the burden of care on
Harborview because it has been shown that, health and social problems are indeed more
common in countries with bigger income inequalities (Wilkinson & Pickett, 2010).
Neoliberalism and the subsequent privatization of care have left an increasing number of people
in need of the services that Harborview provides.
The work of HMC relates to many of the issues we have discussed in class. One of the
issues it relates to is the invisibility of care. Harborview is a government institution that mostly
operates under the framework of neoliberalism. As such, it usually focuses on addressing critical
needs and then relegates much of the long-term care to families. By doing this HMC contributes
to movement to take care out of the public sphere. This movement has obscured the physical and
psychological burdens of care. A job that in a hospital requires a team of highly trained staff is
charged to families, usually to one or two people in particular. This is often a coercive process.

Society has certain status obligations that exert much pressure on these families members and
significant others. This process is made coercive by the fact that, at present, not only are there
no clearly defined limits to the burden that an individual or family group can be expected to take
on, there are no clearly accepted means of exit (Nakano-Glenn, 2012). The individuals in this
position dont have many alternatives from which to choose from. More recently Harborview has
been working to alleviate this burden for patients and families. In 2012 it launched The Palliative
Care Center of Excellence. The goal of this center is to improve the quality of living for families
and patients via specialized care for people with serious illnesses. This program was developed
with an understanding of the fact that as the baby boomer generation ages, there will be a
growing need for this kind of support for patients and their families. As put forth by NakanoGlenn and many other scholars, the United States and other industrial countries need innovative
solutions to face the challenge of caring for a growing number if elderly and disabled citizens
(Nakano-Glenn, 2012). Though this program does not completely alleviate the burden of caring
for a seriously ill family member, it does offer caring support on many levels. To me this
nuanced reality was the greatest difference between in-class learning and service learning. The
concepts presented in class were more straightforward. Each issue was addressed in isolation,
which made it easier to make judgment on them. Service learning forced me to face a much more
complex and nuanced reality. There is no easy or obvious judgment to make about Harborview.
Even at Harborview, which strives to give dignity to the poor and to value those that do
care work, one can see evidence of mainstream attitudes to those labeled poor and those doing
care work. There are many social forces that shape these. Among them are: media, politics,
idealism, and history. These social forces allow people to misunderstand, or even ignore, the
need for care and our responsibility to act. While interviewing Debra, one of the Patient Family

Liaisons, she described her job to me as, soft work. This description would lead one to
incorrectly assume that she has an easy job. On the contrary, I have witnessed first hand the
emotional strength the Patient Family Liaisons need to be effective. Their care work is
invaluable. Amid the frantic activity of a high capacity hospital, patients and families are
extremely thankful to have a group of people solely committed to making them feel more
comfortable. Comfort is hard to come by in an environment full of loud machines, sterile rooms,
and an overwhelmed medical staff. Patients and their families constantly thank us for the warmth
and kindness shown to them by the Patient Family Liaison department. Debras belief that she
does soft work, in my opinion, is unfounded and is probably a product of the historical
devaluation care work.
Care has been devalued in many ways. In the United States care has been devalued via a
narrative that idealizes individualism. Individualism asserts the autonomy and independence of
the individual. It is based on the assumption that all people receive equal opportunity and that,
consequently, individual merit determines success (Fraser & Gordon, 1994). In current American
culture this ideology has succeeded in establishing a dichotomy between independence and
dependence. Independence is understood to be freedom from the control, support, or aid of other
individuals or institutions. In contrast, post-industrial dependency is understood to be an
individual character trait like lack of will power or excessive emotional neediness (Fraser &
Gordon, 1994). Accordingly, independence is seen as an ideal to strive for, while dependence is
seen as something individuals should strive to escape. Currently wage labor confers
independence while charity and welfare confer dependence. This framework obscures a reality in
which people do not have equal access to a job paying a living wage. This framework also

obscures the need for care. By assuming the autonomy of the individual, individualism makes
invisible the caring work all human beings rely on for healthy development.
Care work has been able to remain invisible, in part, because it has historically been
assigned to women and people of color. One can see evidence of this historical bias at
institutions like Harborview, where ideas and expectations of who should do care work have
clearly influenced the gender and racial distributions of certain positions. In the medical field
doctors are the most removed from the dirty work of caring for sick individuals. At HMC most
of the doctors are white males. Nurses and nurses assistants are responsible for the bulk of the
caring work in most medical institutions. At HMC most of the nurses and nurses assistants are
female and many are also immigrants. This bias extends to spiritual support staff, emotional
support staff and custodial workers, to varying degrees.
Based on what I have learned this quarter I do believe that there are many opportunities
to engage in ethical and caring action. However, ethical care needs to be done in a purposeful
way. Ethics is not a static thing, but something that is constantly evolving (EIESL Project, 2011).
Acting ethically requires awareness of this reality. Time should be set aside for evaluation and
reflection, before and after decisions regarding caring action are made (EIESL Project, 2011).
Ideally one would have an awareness of the research done on ethical practice. The four elements
of care ethics discussed in this class, for example, set up a framework that is very useful when
analyzing the caring actions of organizations. Ethical care should be a practice that involves
theory and action (EIESL Project, 2011). Though there is much power in ethical care work, it is
important to recognize its limits. Lasting change in our current care system will require structural
transformation and a society wide rethinking of our current understanding of care.

For its part I found Harborview to be very successful in meeting its own goals. Upon
reflection I have found that, despite its success, HMC does not completely fulfill all of the
elements of care ethics. Harborview is able to recognize the need for care in others. I think that
much of its success actually comes from an underlying awareness among staff and volunteers of
the role HMC plays in serving the regions most vulnerable populations. As an institution
Harborview has continued to develop and improve upon programs designed to help HMC better
serve the communities it prioritizes, such as the programs previously discussed. The hospital is
also able to assume responsibility for meeting the needs of others. Harborview does not turn any
body away. Even people from other medical institutions have told me that if they cannot help an
individual they will send them to Harborview. As the financial burden of medical care has grown
more and more people have come to depend on HMC. Unfortunately Harborview is limited in
how competently it can meet peoples needs. Most of the people that come to the hospital have
needs that extend far beyond acute medical issues. Once they are released, these people are left
with the challenge of caring for chronic medical issues, drug addictions, poverty, etc. Though
Harborview has many programs meant to address some of the issues, they are limited in scope
due to limited funding. This is definitely the case with its Patient and Family Liaison program,
which does not have enough employees to give every patient the same amount of support. These
programs rely heavily on volunteers. However, volunteers can be hard to come by and are not
usually as consistent and reliable as employees. Harborview is also limited by the current
structure of healthcare, which places most of the long-term burden of care of family members
and significant others. Harborview has taken some steps in alleviating this burden (via The
Palliative Care Center of Excellence). Though there does seem to be much work that can be done
in this regard. Finally, HMC is limited in its responsiveness to how adequately care is provided.

From my interview with Debra I learned that all patients are provided with a survey at the end of
their stay. The results of these surveys are dealt with on a departmental basis. The impact of these
surveys is unclear. The evaluative process is also limited by funding, especially for departments
such as the Patient and Family Liaison Department.
My work at Harborview Medical Center and my participation in this class have given me
a much richer understanding of care. Before this class I did not recognize our current care system
as an institution with its own labor market, discourse, and injustices. Learning about care has
motivated me to become more aware to issues regarding care. Analyzing what it means to be
care ethical has given me tools that I will continue to use in my engagement with caring work.
This class has been of particular importance to me because of my interest in entering the medical
field. I hope to apply the principles I have learned in my future medical practice.

Works Cited
Ethics of International Engagement and Service-Learning Project. Global praxis: Exploring the
ethics of engagement abroad. Vancouver, BC, 2011.
Fraser, Nancy and Gordon, Linda. A Genealogy of Dependency: Tracing a Keyword of the U.S.
Welfare State. Journal of Women in Culture and Society 19 (1994) : 2
Harvey, David. A Brief History of Neoliberalism. Oxford: Oxford University Press, 2005.
Massey, Doreen. Geographies of Responsibility. Geogr. Ann. (2004), 86 B (1): 5-18
Nakano Glenn, Evelyn. Forced to care: coercion and caregiving in America. Cambridge:
Harvard University Press, 2012.
Wilkinson and Pickett. The Spirit Level. New York: Bloomsbury Press, 2010.