The Mouth of the South
Full disclosure - I grew up in a tiny town of 2,000 residents outside of Memphis, TN. Unaware of all the privilege bestowed upon me by my skin color and the fact that I was a preacher's child, I moved through this world unaware of the pain and suffering borne by anyone who sought self-expression outside of this white, male, heteronormative, hyper-masculine world. As a child, I felt safe in an environment where it seemed normal for everybody to know everybody else's business. As an adult caring for people living with HIV, I now see all too clearly the ugly side of small town life.
During my 10+ years at the Vanderbilt Comprehensive Care Clinic, I cared for patients from every walk of life and every living situation, from those experiencing homelessness to those living in multi-million dollar homes. I cared for many people from small towns, as well as those who had never ventured outside of Nashville, TN. The level of comfort with having HIV that my small town patients demonstrated seemed encouraging, and only rarely did anyone voice any concerns with small town life.
Early in 2022, I began seeing patients at two small, rural, Tennessee Department of Health HIV clinics. It was only then that I realized there was a gaping hole in my understanding of the realities of urban versus rural HIV here in TN. During my first few clinics, I approached my patients as I had while working in an urban setting, and I was a little surprised by their reticence to engage with me. At first, I could not figure out what was happening and why my proven clinical skills were failing me. As she has done many times before, my dear friend and PATHways collaborator Karie Holldorf unlocked this puzzle for me. The key was realizing that the rural patients I saw in an urban setting sought out care in an urban setting and were comfortable there. Those patients were comfortable in my environment. I had mistakenly assumed that their comfort in my environment meant they were equally comfortable in their home environments. Nothing could have been further from the truth.
There is at least a possibility of anonymity in urban living that is not possible for those living in smaller communities. The interconnect-edness that is supposed to be protective for all members of the community only works when it is extended to all members of the community. Why is it the case that who a person loves and how that love is expressed has become the litmus test for inclusion in so many cases? That is a difficult question to answer, especially when I am determined to avoid easy tropes of the urban sophisticate versus the rural rube.
The underlying issue is one of power, and our seemingly innate need to stratify the world into categories of people with more or less power than we have. It's a well-worn axiom from the ugly Southern politics of the 1960s, but it does seem to be true that people will tolerate any of a number of insults so long as they are assured that they can shower disdain on others in a manner that imitates the distain they feel from groups "superior" to them. If power dynamics are at the root of small town gossip and exclusion of individuals who do not conform to whatever the group decides is the norm, how does one address that? How can we empower those being marginalized? Sadly, it's not possible to appeal to the majority to collectively change their behavior. It's also not a question of identifying and suppressing individual voices causing harm - it's the fact that then entire environment is toxic to people who live outside whatever the majority decides is the norm. The key is to realize that the best way forward is the slow work of empowering individuals toward greater self-efficacy in these toxic environments.
We urgently need to re-design current approaches to care to be more flexible, more accepting, and more welcoming in order to create healing environments for marginalized and traumatized patients. Not everyone needs a full 30-minutes, and some people need an hour. The PATHways Program that I developed and ran, along with an amazing team, demonstrated that it is possible to reach and empower marginalized people living with HIV. You can read more about the PATHways Program and our team's successes here. It is possible, it is even imperative, that we change our models of care to provide care to more people living with HIV.
