A Place to Breathe Filmmaker Michelle Steinberg speaks on Healthcare and Community Healing
Interviewed by GOOD DOCS intern Munji Nfor
What inspired you to make the film A Place To Breathe?
The film initially came about because of my years of work at one of the clinics featured in it, Street Level Health Project. I would hear the stories of my patients and colleagues, and was given the opportunity to examine what types of healing seem to support the well-being of the communities that we serve. In 2016, a colleague in an organization that I was previously on the board of, called Integrative Medicine for the Underserved, shared an article about Metta Health Center in Lowell, Massachusetts, which was doing similar work in different communities. At that point, it clicked for me that there are other places also engaged in integrative, culturally responsive healing, and it would be interesting to look at that story from a variety of perspectives.
How do you believe your background of being a bilingual nutritionist and herbalist contribute to your direction of the documentary?
I've had the privilege of being able to work cross-culturally for many years, attempting to provide culturally responsive healing. It’s been incredibly inspiring to engage the wisdom of my patients and of the communities in which I work, and learn what types of healing practices resonate with people from a number of different backgrounds. I think that through the course of my work and the film, what became obvious to me is that while it's important for those of us working cross-culturally to look at how we show up and are culturally responsive to our patients, it is especially critical that we focus on the work of people who are providing healing within their own communities. For that type of healing, I like the term culturally rooted, as opposed to culturally responsive, because it comes from the community itself. For the film, we chose to celebrate the work of community health workers and providers who practice in their own communities and what that interaction looks like. To be clear, by ‘we’ I am referring to myself and my co-producer Robyn Bykofsky - she was an instrumental partner during the entire process.
In this documentary, we see immigrants on opposite sides of the country facing similar scenarios. Why did you choose to focus on the communities in Lowell, Massachusetts and Oakland, California?
I'm originally from Washington, DC, as is Robyn, but we've each lived in Oakland for many, many years. Oakland is now my home, so it was intuitive that many of the stories I wanted to share come from here. It was really happenstance that I was exposed to the work that Metta Health Center is doing. It became a nice point of compare and contrast, since they tend to work with different communities than my clinic. Another important aspect for me is that there are so many different immigration statuses that people have in this country. There is an unfortunate hierarchy that exists in relation to one’s legal status, which tends to obscure the human experience behind it. Some people are permitted to come as refugees, some people come seeking asylum, and in that case, are not permitted refugee status in advance. And other people won't even be able to qualify for asylum, despite having survived very similar conditions. So it's a very political designation that actually does a lot of damage to people's lived experience. For me, it was important to look at stories from different communities and populations, and recognize that while the historical context of people's experiences are unique, the trauma itself, and some of the major components of their journey, can be very similar. Yet, how people are treated when they get here, and what services are available to them can differ significantly. As healthcare providers, ideally, we are looking to support people regardless of their legal status, and do so in the most culturally responsive, welcoming ways possible.
What were some of the challenges you encountered while working with individuals that had citizenship insecurity or were concerned about visibility?
Anytime you are filming a documentary, you need to get consent. But we had a higher level of accountability; both because of people's immigration situation, and also because we were dealing with healthcare. So we had the HIPAA laws, which protect people's privacy as patients as well. For instance, one of the characters that you see dealing with a very traumatic situation, we didn't disclose her name for safety reasons. At other points, we didn't disclose people's last names, or there were various measures taken. We consulted with an immigration attorney to make sure that nothing we would be doing would put any people in the film in jeopardy. It was something we were very deliberate about. Just as in medicine, in filmmaking, I hope we do no harm and that requires taking the time to ensure that your project will not end up creating problems for people who trust you to share their stories.
What differences in communication regarding trauma and healing did you notice between young and old members of each community? Can you give us an example?
I think it's better for the film itself, maybe, to speak to that. There's a point where Sonith Peou, who was the Director of Metta Health Center at the time when we filmed, states that older generations that went through trauma often want to protect their families from hearing about that experience. I feel uncomfortable making any generalizations from community to community, even from individual to individual, because everyone handles things differently. I did notice that in certain cases people were willing to reflect on things in front of the camera or with us that they might not necessarily have engaged directly with family members. And I'll just say that created some complicated feelings for us about what then is appropriate to share publicly versus what type of privacy people need. I think that's a really fluid question. Also, I think it's important for filmmakers, or anybody doing work around trauma, to recognize that the boundaries can change from one moment to the next as far as what people feel comfortable with. So people might agree to share something in an interview and then later feel uncomfortable with what was disclosed. I know for us, a huge part of our process was that both draft versions and final cuts of the film needed to get shared with the people in it, prior to any kind of completion; because we just want to make sure that whatever goes out in the world, is something that people are comfortable with. But like I said, I think that it's really important to be mindful of the fact that that can shift over time, and so maybe the best you can do is ask for people's feedback and give people the power to make those decisions. Then if that shifts later, try to show up with the resources that people need to address what's coming up for them (for example: support for traumatic emotions that may come up following screenings.)
Animation is used throughout the film and often depicts traumatic and violent memories of the subjects of the documentary. What was the reasoning behind this creative decision?
We chose to use animation because even when people gave consent, and seemed to feel comfortable relaying some of their traumatic memories, it felt more vulnerable for both them and potentially the audience, to have them on camera in those moments. We wanted to create a way of explaining what they experienced that wasn't gratuitous. So it was very important to us that certain situations were portrayed more metaphorically in the animation to speak on a deeper level, and hopefully provide a little bit of privacy and space to contain the person's experience. We also wanted to create a separate space to depict what happened in the U.S. versus what happened in people's homelands, and so that home space that was contained by the animation. We had an exceptionally positive experience working with the animators. We found two women who worked remotely. This was just prior to COVID. We were learning what remote work looked like right before the pandemic hit, which became useful because we had to finish the color and sound on the film remotely a few months later in Spring 2020. One of the animators was based in France and one of them was based in Germany, and they didn't know each other and had never collaborated before. But due to our time deadlines, we needed two people in order to finish. They divided up the work and managed to both have their own styles, while also keeping a consistent feel throughout. Then it was super important to us that those sections reflected the feeling, the colors, and the sounds that felt familiar to the people whose memories they were. So at multiple stages in that process, we sent storyboards, color schemes, all of that to the families. Then we showed them drafts and final versions of the animation to make sure that it felt consistent and familiar to their experiences, and that they had some kind of participation and oversight in creating those experiences.
Rodrigue and Yania became inspired to study social work and nursing, in order to give back to their communities. What do you think can be done to raise awareness about their experiences, so that these communities can receive additional support outside of their own members?
I think that it's really important that people have role models who are doing work in their own communities. We'll discuss it in more detail later, but we're working on a curriculum that will allow more visibility to this type of journey and more respect for the type of journey that people who become providers in their own community have, because a lot of times I feel like the importance of that aspect gets invisibilized. I know that, for instance, the World Health Organization used our film during a series of programming that they did in Turkey. During that event, it was specifically focused on how the WHO and the EU were setting up clinics for Syrian refugees in southern Turkey. Yania (featured in the film) and I both spoke on a panel related to that initiative. There are many complicated political dynamics that are probably outside the scope of this conversation, but I know that one thing that was very notable to me was that on the panel as well was a doctor from Syria. I think that that's a really important practice that people who are already medical providers, who are trained and educated in their own countries previously, are fast tracked so that they can show up and provide the services to their own communities when they have been displaced. This doesn’t happen very fluidly in the U.S. So I think it's kind of three pronged: first, how can we fast track people who already know how to be healthcare providers in their own communities to be able to continue in that role when they come here; Second, for younger generations growing up here, how can we make education as available as possible so that people can choose to go in that direction when they want to; and then lastly, how can we see people who are serving in that capacity, in other less formal ways, that haven't always gotten the same level of respect and how can we elevate them, whether it's an acupuncturist or a Community Health Worker. How can we elevate those voices as central members of the healthcare team, since they often represent the voices of what patients prefer.
As a side note: When I am asked to speak, as a filmmaker and healthcare provider, I strive to include those whose stories appear in the film to speak for themselves. GOOD DOCS also has Rodrigue and Yania as designated speakers, and depending on the situation, other people from the film have joined us to speak about their experiences as well.
Cultural competency and traditional healing practices are heavily emphasized in the healthcare centers you introduced to us. How do you think community-informed care impacts these populations, compared to the standard Western approach?
I know that Sonith refers to cultural competency in the film. For me (and this is not necessarily true for everybody who's helping on the curriculum as people have diverse perspectives on this), I'm not a fan of that term. Because competency, to me, suggests that there is some level that we can reach, that results in being proficient at something, and I don't think that proficiency is enough. A term that I have more affinity with is cultural humility, which is the idea that it is a lifelong journey to recognize how we can do better in seeing both where we're situated and how that relates to how other people, in this case patients and community members, are situated. I think for people like myself, who are working cross culturally, the aspiration is to be more culturally responsive, which constantly involves the self awareness and criticism of being culturally humble; then for people who are actually practicing in their own communities, it's culturally rooted, because their position goes far beyond any connotation of cultural competency and should be recognized for the value that it brings.
How do you believe the U.S. healthcare system can better approach making its services accessible, reliable, and secure for immigrants and refugees?
First and foremost, by bringing immigrants and refugees into the room while creating the services. On the one hand, language accessibility and making sure the visual aspects of the clinical setting feel culturally welcoming. But most importantly, employing Community Health Workers and providers who themselves come from the cultures and communities being served, and ensuring that the modalities of healing that are most familiar to patients are equally represented and made accessible in that same context and conversation.
How do you hope to see your film be used in educational settings? How can we help further these goals? (For example: medical school training sessions and undergraduate lectures)
We are in the process of developing a curriculum in partnership with the University of California San Francisco, with funding from UCSF and the California Health Care Foundation. It will bring UCSF medical students, nursing students, physical therapy students, pharmacy students into classrooms with students from the Community Health Worker and Health Interpreter programs at San Francisco City College, as well as acupuncture students from the Academy of Chinese Health Sciences and Culture. As an interdisciplinary group, these students will use the film and their own experiences to focus on trauma, healing, and culturally responsive healthcare. The curriculum creation process is a team-based effort that involves eight people who all bring different perspectives in terms of their cultural and healthcare backgrounds. In addition to evaluating the inequities of the current healthcare system and its ubiquitous structural racism, the curriculum will focus on how to create non-hierarchical team-based care that really centers the wisdom of patients and healthcare providers from their own communities. It will look at healing as an integrative process that centers traditional healing practices and modalities that are specific to the communities being served, along with Western medicine and social determinants of health.
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