Doing Justice, with a Little Neeb: From Libraries to Public Health and Back

In Hmong culture the twix neeb is a traditional healer who is consulted for treatment of illnesses. The Spirit Catches You and You Fall Down, Anne Fadiman's 1997 ethnography of a refugee family, depicts the misunderstandings between a small, California county hospital and the Lee family, whose child suffers from severe epilepsy. Mr. Lee suggests we “use a little medicine and a little neeb,” that is, to incorporate cultural practices in our approaches to all of our interactions.1 I think we can all practice a little neeb.In the spring of 2020, when COVID-19 touched down in this country, City and County of San Francisco employees were quickly mobilized as disaster service workers and assigned to various tasks throughout the city. Many San Francisco Public Library (SFPL) librarians and library technicians including myself became contact tracers with the city's Public Health Department (SFDPH) in the first such program in the country. It developed into a robust and innovative, household-centered, case investigation/contact tracing program.Contact tracing involves a balance of information seeking and information sharing. Our job was to give appropriate guidance for each person's situation, utilizing computer technology including softphones, databases, and videoconferencing. Well-practiced reference interviewing skills successfully transferred to this new work. A contact tracer added, “My separate mission was to listen to people and make them feel like they were supported by the city, and I wanted to take the edge off that feeling for people in a time that might be frightening to them. Sometimes I just listened.”2 Furthermore, experience with confidentiality matters allowed us to gain trust from those identified as cases and their close contacts, and was helpful in following Health Information and Portability and Accountability Act and California privacy laws.Librarian Lisa Fagundes commented, We were telling strangers they are ill and trying to soothe them. It was delicate; you had to probe to get the information to best help them and keep their loved ones safe. While the stakes aren't usually as high in a reference interview, it pays to be able to sense when to ask a patron a clarifying question, and when to just listen.3Some librarians have documented this history-making: Fagundes kept an audio diary of her year, Lyn Davidson is recording the experiences of redeployed city workers, and I am gathering print documentation.4 Collecting these stories and materials now ensures that they will not be lost, and will provide scholarship on public health, equity, and work practices.During the winter surge of infections, I moved into case investigation. This required more deftness in evaluating the responses and using the database to take next steps such as notifying airlines or workplaces. A colleague described the transition as akin to The Tubes/big band mashup scene in the 1980s musical fantasy movie Xanadu, and that we were hip hop dancers, because of the new methods of practice and communication styles. Being curious, which also applies to my library and archives work, I would study the case data to develop the big picture. I tried to uncover the trajectory of the disease and to coax overlooked contacts' names such as housekeepers, cooks, and drivers. Similarly, I might research a library reference matter or provenance of a collection, or history of an individual or agency, to get a better understanding before proceeding.The training and support by public health professionals from the University of California, San Francisco (UCSF) Pandemic Initiative for Equity and Action (UPIEA) team, in collaboration with SFDPH, was outstanding. Presenters included Dr. George W. Rutherford, head of UCSF's Division of Prevention Medicine. Early on, he shared relevant statistics in a friendly, digestible way and explained how the “spiky” SARS CoV-2 virus replicates. He recently commented that he stapled his vaccine card to his passport because “that's how optimistic I am.”5Messages from Dr. Michael Reid, who oversaw our work, were poetic and uplifting. In December, as the virus surged, Dr. Reid shared a beautiful 1995 essay written by Dr. Eric Goosby, his then-UCSF boss. The piece closed with words inspired by Robert Frost: “We have miles to go until we sleep. We have promises to keep.” Mike added, “Our collective work is so much more than just making phone calls. We are not just a vaccine stop-gap. We are transforming lives, bringing light into darkness, hope where there is despair.”6Later, UCSF emergency physician Dr. Ellen Weber broke down the mechanics of the vaccine and informed us on related matters including variants, genomic sequencing, and breakthrough infections. She is currently advising team members who are making vaccine appointments for residents. A colleague mentioned how extraordinary it was to have clinicians at the ready.Understanding the medical guidance was key to advising our contacts and cases. It also led us to seek clarification from the medical professionals when necessary, and to make appropriate clinician referrals. This was similar to, yet beyond, what we do or will do as librarians, which is to bring our users to appropriate information. I believe the collective sense we gained—that we helped save lives—contributed to our renewed dedication to serve our library users with excellent access to the best information.Although librarians figured prominently in the press, team members included UCSF personnel and city employees from multiple departments, with leadership from the Public Health Department. The first case investigations began on March 6, 2020, at 25 Van Ness Avenue, steps from City Hall. With a growing staff, the team relocated two months later to the Moscone Convention Center, joining the city's COVID Command Center. The facility, normally home to technology conferences and automobile shows, housed a mass vaccination site beginning February 5, 2021, considered a turning point in the disease's trajectory. Many of our team worked remotely from home.The team grew from a handful of 7 to 313 tracers and investigators. Overall language capacity was 36 percent Spanish speakers and 6 percent Mandarin or Cantonese speakers, with significantly higher capacity beginning in February. Joining were nearly 100 individuals from sixteen community-based organizations, bringing language and cultural concordance. The groups included Rafiki Coalition, the San Francisco AIDS Foundation, Dolores Street Community Services, and the San Francisco Community Health Center. We also worked with people from around the state, some of whom began their efforts in regions with high infection rates and few resources. Among the benefits of having community representation was our staff's increased awareness of the diversity of Latin American cultures in San Francisco, specifically Guatemalan Mayan people. AIDS Foundation staff contributed cultural humility and shared tips on identifying LGBTQIA needs, such as referring to cases and contacts as they instead of assuming he or she until or unless they identified their gender, and advocating for confidentiality when soliciting workplace information.When possible, we conducted interviews in the subject's preferred language, enabling comfort and trust. With infection often spreading through a household, a colleague related how her Cantonese-speaking case unexpectedly responded with laughter during a follow-up call, having previously developed rapport.Although I am a monolingual English-speaker, I joined an Asian language-speaking buddy group and observed some case interviews. From this and other cultural and community sharing, I picked up on subtleties and care in understanding and using words and phrases. The cultural tendency to avoid discussions of negativity during the Lunar New Year led me to use more care with calls to Asian households during that time, asking if we could make a plan together to keep their families safe. It was further noted that Chinese American adults who tested positive sometimes felt shame in sharing this with their elderly parents. A colleague reported that her Spanish-language skills improved during last summer's surge, when nearly 75 percent of her cases were Spanish speakers. We also worked with interpreters and learned how to more effectively convey a humanistic sense through a third party.Other learnings included noticing someone's hesitancy, which could lead to a more nuanced response from the investigator. Similarly, understanding how distrust in medicine and government might play into responses could inform our tasks, which carries over into our library work. Accordingly, working with folks from diverse communities of our city and state, as well as with those with other language skills, taught me humility and how to be a better listener, professional, and human being. To you, kansha shimashita (I am grateful).Partnerships demonstrated a powerful strategy. A prime example was the UCSF and Latino Task Force collaboration, which began offering rapid testing at the 24th Street BART plaza at the beginning of the year. The Mission District was then home to a large COVID-19-positive population. With lack of vaccine supply, this low-barrier, regular testing produced an outsized percentage of the city's cases. Rapid testing allowed us to then reach these cases and their contacts more quickly and assist them with isolation and quarantine. The collaboration also runs a vaccine site nearby. Opening pop-up test sites in targeted neighborhoods and relocating a large, low-barrier test site to the city's southeast sector was sensible and effective in reaching high-infection areas. Libraries are good at this type of collaboration.I think all team members would describe the work as meaningful and positive, contributing to the health, well-being, and economy of our communities. Many related how uplifting it was to have appreciative “clients.” Acknowledgement was frequent. One of my contacts, a cancer survivor who was probably my elder, said, “I love you, Baby!”Significantly, working with cases and contacts appears to have been easier for staff with extroverted personalities. This may also be true for libraries and other public-facing organizations. I probably enjoyed the work particularly due to this aspect, while a colleague with an introverted personality said that, initially, their heart raced before each call, which took some months to overcome; now they miss it.Gathering in daily teams was empowering and enhanced our work. We were in constant communication with our colleagues, necessitated by the urgency to provide guidance to our cases and contacts, and to make timely and appropriate referrals, for example to the schools' outbreak group or to food or housing coordinators. I believe being able to offer food, housing, and cleaning supplies made us feel enabled. I later spoke with a public health professional in Southern California who said the contact tracers they knew reported negative, difficult experiences. I don't know if other cities and counties were able to widely offer such aid. Being well trained and having good and frequent communication, regular wellness sessions, and opportunities to mourn the national tragedy of racial injustice as well as celebrate our public health efforts all created a positive work environment.Rock star guests including Dr. Anthony Fauci, Golden State Warriors coach Steve Kerr, and writer Anne Lamott spoke to us via our community of practice videoconferences. Coined by the social theorist Etienne Wenger, a “community of practice” is a group of people that comes together, often around a professional endeavor, to learn from each other, find solidarity, and grow professionally. Jessica Celentano of UCSF's Institute for Global Health Sciences, shared, Ours was named “What a Week,” and served as an opportunity at the end of a very long week to come together to celebrate our accomplishments and hear from a range of experts in areas relevant to wellness—artists, musicians, community members. The whole goal was to keep the community united and motivated and centered around our core mission.7The weekly forums became alternately offered in English with Spanish translation and in Spanish with English translation. In addition, daily wellness offerings provided safe physical and psychological spaces to refresh our souls and bodies. In one of two surprise visits, as cases soared, Dr. Fauci, told us, “There is light at the end of the tunnel.”8Ets-Hokin reported, “It was understood that CI/CT was stressful, and it was okay not to be okay. It was expected for us to struggle, and they actively encouraged wellness in a way that made me feel comfortable accepting it.”9This was impactful work—helping to stop this relentless virus and bring safety to our city and communities. It became clear to me that this, and all public health work, is equity work. Librarians and archivists are also committed to equity, making this temporary, sabbatical-like assignment even more rewarding. Daily new case figures, using a seven-day rolling average, were at a high of 373 in mid-January of this year in San Francisco, and averaged 13 as of late May.I was previously somewhat oblivious to the impact of public health on all our lives. Successful public health efforts often go unnoticed due to their success. Public health “is the science and art of preventing disease, prolonging life, and promoting health.”10 We might only read of a disease such as Zika or Ebola affecting a far-away population. We might not consider food scarcity, drug addiction, and homelessness as public health issues. Likewise, we might not realize that toxic environments, such as those with ground or air contamination, are public health and environmental justice matters. Public health practitioners explicitly work toward equity in all that they do.Coincidentally, just prior to COVID coming into our lexicon, the city's public health director, Dr. Grant Colfax, spoke to SFPL personnel on the city's health agenda. He commented that he believed all public health matters can be solved by education, and that libraries can play a significant role in these efforts.11 Global health leader Dr. William Foege has said, “Public health is science with a moral compass.”12The pandemic expanded amidst widespread demonstrations over police brutality and systemic racism in this country, and in response to the killing of George Floyd. This movement, acknowledging racial injustice and the continuing loss of Black lives, exploded while communities of color were disproportionately impacted by the coronavirus. Both SFPL and the DPH contact tracing groups have had provocative discussions on the tragic and centuries-long challenges faced by our African American, Latinx, and Indigenous siblings. Words shared in our focused community of practice meeting included disparity, caged minds, no escape, loss of dignity and self-worth, loss of life and diminished quality of life, loss of dreams, and living in two worlds.13 The intersectionality of various forms of inequality and how these exacerbate each other were also noted. We are forced to acknowledge our privilege in education, professions, connections, neighborhoods, and environment—the soil, the air we breathe and water we drink—and in income and wealth, food, healthcare, liberty, the pursuit of happiness—everything. If there is to be justice, healthier and more vibrant communities, and shared bounties, we must accept collective burden and social responsibility.In a meeting on Black excellence, Dr. Monique LeSarre of Rafiki suggested we approach all aspects of life with more compassion, love, and grace, and to know that we are all deeply connected. As former First Lady Michelle Obama has stated, how we see each other is really about us.14 We are moved to look at what we bring to our work and the world, including our biases, and how we can contribute to equity.Are we creating space and empowering those who are disadvantaged and have historically faced tremendous burdens from the wages of acculturation, slavery, and stealing of lands? Are we providing cultural and linguistic competence? As archivists, are we collecting and making accessible histories of all people—covering races and ethnicities, gender expression and sexual orientations, and abilities? Are we describing our collections and cataloging holdings with a racial equity lens? Are we being intentional, with barrier-free practices and mindsets, in how we do reference; create programs and exhibitions; and work with colleagues, donors, and members of the public? Are we providing reference that is not only technologically accessible but also addresses those who are technologically challenged and accommodates those with disabilities?Professional responses at SFPL include reparative description work in our finding aids and catalog records. Recognizing that stark disparities continue to exist for San Franciscans along racial lines, the library formed its Racial Equity Action Plan as part of its efforts to prioritize racial equity for our workforce and community. Steps include determining the collection of racial data in furtherance of the library's goals, analyzing hiring and recruitment practices, and developing strategies in collaboration with Black and American Indian communities and communities of color.As we resume our library and archives work, we take our new knowledge and experience—more sensitivity and savviness in understanding our subjects' needs and concerns and responding appropriately; and a heightened commitment to improving our communities—with us to be even more effective information professionals. A number of team members mentioned empathy being a main takeaway. Said one: “It gave me new insight into seeing the humanity in each person, and understanding that each individual has a unique perspective, even in our shared experience.”15 They also commented that this experience changed their relationship with work, and that they hope to keep that perspective and attitude towards improving the work environment and practices.Tracer/Archivist Katherine Ets-Hokin said, One of the most powerful experiences I had was during a wellness Wednesday workshop. The guest speaker had us visualize ourselves walking through the city, looking at people as we walked to the Golden Gate Bridge, and then we looked back at the city. Then she had us visualize all the people we had seen on our walk. And then she told us those were our people. This was our city, and those were the people that we saved. I still get choked up when I think about it.16A librarian pointed out that working with the public can be overwhelming, abusive, and depressing, as well as empowering and satisfying. Suggestions include having wellness spaces for library staff to vent and get peer support and adjusting schedules to accommodate difficult moments. They noted that frontline staff need to feel well-prepared for system changes and supported after difficult patron interactions. Another suggestion is for the library to record sexual orientation and gender identification in addition to race data, as we did for the Health Department (in a confidential database). This would allow us to accurately quantify our service and help us address equity.From my pandemic-response experience, I am bringing back more energy to create a space where all employees and library users feel safe and respected, where all lived experience is acknowledged in its fullness. I will affirm and encourage those who are silent and/or feel silenced, however they see fit to contribute. I will be more involved in racial equity matters at our library. I will mentor those who are underrepresented in library and archives professions, with goals of representation and cultural and language competence. I will work harder to reach out to overlooked peoples for their history.Well over a year has passed since San Francisco saw its first coronavirus cases. With improving statistics and multiple vaccines, we are returning to our libraries and historical records, after participating in this astounding history. These are my goals: To be a better listener and have more patience, with others as well as with myself;To see with someone else's eyes and be open to others' life experiences;And to use a little neeb.To all of our team, otsukaresama deshita. Thank you for your good work.