Your Heart is the Size of Your Fist

by Martina Scholtens

  Some patients spilled every detail of their traumatic experiences to the first person in Canada who would hear it, often the nurse doing the screening visit at Welcome House. Some learned to use their stories as a kind of currency, to unlock services and sympathy. One Middle Eastern patient kept a slideshow of horrific images on his phone, set to music. Others kept their stories secret for years, even denying knowledge of how traumatic injuries had been sustained. A young African woman had casually asked my opinion about scars on her back, dozens of fine white horizontal lines laddered over her spine. I was at a loss as to how the markings could spontaneously appear. A year later she revealed that she’d been whipped; she didn’t disclose why.

  A few patients appeared remarkably unscathed by awful experiences. A Syrian politician who had had a cavalcade of thirty cars pull up to his home to arrest and imprison him for five years exuded such peace that I felt compelled to ask him about it. He told me with deep satisfaction: “Life is about the message. I had a message and for years I gave it to the people that needed to hear it. When I was jailed, they took away my freedom, my wallet, my health—but they couldn’t take away my message.”

  Cultural attitudes toward past events differed, too. I’d asked a Myanmar woman once what she talked about over tea with her neighbours, also newly arrived refugees. “Do you talk about life in Canada, or the old days in the camp?”

  She’d looked shocked at my question. “We talk about life in Canada. Everyone knows to talk only about our new life!”

  An Afghani patient, on the other hand, had once recited a proverb to me: “One thousand years is not too long to hold a grudge.” She, and others in her cohort, had had a very difficult time moving forward with a new life in Canada.

  Over 80 percent of refugees exposed to trauma recover spontaneously upon reaching safety.2 Research shows that patients’ mental health benefits from attention to basic needs, such as shelter, language acquisition, and the ability to work or attend school. And so I didn’t press Yusef on his experience. I gave him an Arabic version of Canada’s Food Guide and directions to Canadian Blood Services on Oak Street.

  8

  THE PATIENT WAS A YOUNG Iraqi mother. When I asked her how she was doing, she spoke so quickly that Hani couldn’t keep up with the interpretation. Suddenly the patient stopped talking and dug in her purse for her phone. She stabbed at the screen with her index finger. She was going to show me a photo, I was sure of it.

  This often happened at the clinic, and I never knew what I was going to see. Sometimes it was an album documenting the progression of a rash, blotchy red patches spreading over a torso. Once it was a picture of the patient in his previous life, standing in front of a grand home with an orange grove out front. And sometimes patients showed me something terrible: third-degree burns sustained during torture, or a crucifixion.

  She passed me her phone, the screen filled with an image of dead bodies in someone’s home. I looked at the picture like it was my job, because it was. It was part of caring for this patient. Something didn’t make sense, though, and I automatically did a finger spread, zooming in, only to realize that the bodies were mutilated. I handed the phone back to her, and she looked grimly satisfied. The visit ended soon after. She didn’t need anything else.

  When I called Yusef from the waiting room a half hour later, the young Iraqi mother was sitting on one of the pews, and she blew kisses at me with both hands.

  “I have burning,” said Yusef once he was settled in the exam room.

  “Where?”

  “Everywhere.” He gestured expansively at his arms, legs, and abdomen.

  “What kind of burning?” I asked. “Tingling? Numbness? Pain?”

  Hani explained these subtleties to Yusef.

  He considered them. “Only burning,” he said.

  Almost weekly, Yusef checked in to the afternoon walk-in clinic with a similarly vague complaint: fleeting central chest pain while riding the SkyTrain; intermittent difficulty swallowing rice; excessive belching in the evenings. Each time, I took a thorough history, examined him, and ordered any necessary tests. Every time, the results were reassuring, and the problem migrated to another part of the anatomy.

  I suspected that the diagnosis lay in a simple observation Junah had made at her last visit with me: “Yusef screams in his sleep.” If I was going to ask Yusef about his mental health, I’d have to do it in a roundabout way, without reference to mood, crying, or worry. The stigma of mental illness, ingrained in Canadian society, is even greater in refugee-producing countries. Furthermore, most of my patients did not consider psychological issues to be part of the medical domain.

  I started with my most proven access point to mental health assessment: “What time do you go to bed, Yusef?”

  “Eleven o’clock.”

  “How long does it take you to fall asleep?”

  “One or two hours.”

  “What are you doing during that time?” I knew the answer; I’d heard it a thousand times.

  “Thinking. Thinking.”

  “Do you think about what happened in the past, what’s happening in your life now, or what might happen in the future?” Worrying about one’s daughter making friends in school was completely different than reliving a traumatic event or planning one’s career.

  “Always thinking about the past.”

  “Do you control your thoughts, or do the thoughts control you?”

  He looked startled, found out. A confession: “Thoughts control me.”

  I patted the left side of my chest with the fingers of my right hand, twice. “How are your spirits?”

  Every patient, well-trained by their ESL instructors, dutifully responded, “Fine!” when asked, “How are you?” Enquiring about someone’s spirits while pointing at the heart, though, seemed to be universally understood as permission to divulge one’s actual state of mind.

  “No good,” said Yusef quietly, after a pause. He pulled something from his back pocket, a folded brochure. It was for a local community program, and on the cover was a photograph of an elderly man with his head in his hands, and a consoling friend beside him. Yusef held up the pamphlet, pointed at the photo and looked hard at me. “Me,” he said, his voice breaking. “Me.”

  There was a long pause. “Doctor, can you injure yourself by crying?”

  “No.”

  He nodded, slowly. “Sometimes, when I cry so hard, it feels like something might break inside.”

  He told me what had been done to him by his abductors. He described an assault on the body intended to break the spirit, ensuring he would never recover. The account of inhuman acts was so degrading that I would never allow the details to leave the exam room. I wouldn’t enter them into the electronic medical record or debrief with colleagues. I wouldn’t share even a basic account, stripped of patient identifiers, with Pete or my closest friends.

  In the future, when someone at a family dinner would make conversation by asking me, “What’s the worst story you’ve ever heard at the clinic?” this would be the one I’d think of, and I’d be enraged that someone could enquire so lightly about trauma, wanting only to be titillated, while reaching for ketchup.

  I was turned away from the computer, facing Yusef squarely. I sat with my feet hooked on the stool footrest, my hands on my legs, shoulders loose. I listened. Over the years at the refugee clinic, I’d cycled through various responses to patients’ stories of trauma. The gamut I had run was wide: voyeuristic fascination with the horrific details; avoidance of patients’ pasts when I became overwhelmed by my powerlessness to change them; feelings of deep shame over being human; detachment, where I could hear a story of torture while noting that it was lunchtime, debating whether to order the black bean soup or the cucumber and gorgonzola sandwich at the deli. Eventually, I simply focused on absorbing patients’ stories. I came to believe in the healing power of bearing witness to suffering, a belief borne partly out of results, partly out of resignation.

  When I was first at
the refugee clinic, young and green, I wanted to prescribe treatment for a Congolese patient’s parasite; she wanted to tell me about being raped by her neighbour. As she spoke, slow and soft, I panicked because I didn’t have a plan. None of the usual medical responses applied, in that brisk bullet point way that physicians love—a prescription, procedure, referral. There was no solution. What was I to say when she finished her story?

  Now, a few years later, I taught my residents that it was presumptuous to even think there existed a fix for something of such nature or magnitude. No one shared a story of intense suffering and expected to be offered a solution. As difficult as it was to just listen—to accept one’s impotence—it was enough. And so I said nothing. When he finished speaking, I said only, “I’m sorry to hear how much you’ve suffered. No one deserves to be treated like that.”

  After disclosing a horrific story, patients always did one of two things: they apologized, or they thanked me. Yusef apologized.

  That night, two girls walked into a bar. A bistro, actually, a block from the Park Theatre on Cambie Street, where The Grand Budapest Hotel was playing. And we weren’t exactly girls anymore, with six kids and two thousand patients between us. The bistro had a bar, though, and my friend Erin and I had a half hour till show time.

  She ordered a beer and I had a whiskey sour. The place was packed, Friday-night noisy. I poked at the ice in my glass with a straw, and Erin told me about a case from her practice in Comox. The server approached with a tomato and bocconcini salad, a glorious trifecta of tomatoes, basil, and cheese with the balsamic drizzled artfully across the plate. I expected her to pass by, but she stopped and reached over to set it down between us.

  “That’s not ours,” I said, regretfully.

  She looked confused.

  “It’s not ours,” I said again. “Not unless someone ordered it for us.”

  She took it back, apologetic. “Your face just lit up when you saw it,” she said.

  “It does look delicious,” I admitted. We laughed, she brought it to the couple a few feet up the bar, and Erin and I returned to our drinks and conversation.

  Ten minutes later, the waitress approached with another tomato and bocconcini salad. She set it down in front of me. It was déjà vu, except this time the bartenders and another server paused to watch, smiling.

  “Someone ordered this for you,” she said. We stared at the plate.

  “The guy that was sitting at that table over there,” she said, gesturing behind us. “He ordered this for you.” I turned, and he was gone, leaving just a crumpled napkin and the bill folder on the table.

  Our show was about to start, but I enjoyed every slice of Roma tomato, every pale oval of cheese, every basil leaf, and with each bite I thought happily: A stranger bought me a bocconcini salad, anonymously, simply to delight.

  I’d recently read a description by American essayist Phyllis Theroux of an ecstatic experience where she watched the morning sun light the cockleburs next to a sleeping porch. This was an experience from which she drew strength later:

  Could it be, and this is the question of a speculative, unmarveling adult, that every human being is given a few sights like this to tide us over when we are grown? Do we all have a bit or piece of something that we instinctively cast back on when the heart wants to break upon itself and causes us to say, “Oh yes, but there was this,” or “Oh yes, but there was that,” and so we go on?1

  A few weeks earlier, I’d seen media images of captured Iraqis before and after execution by militants. I saw their faces and hands. I struggled to grasp that humans treated one another that way, and I couldn’t make sense of it. Then I read an article in the Guardian about men being raped in war, and it fit exactly with my experiences at the refugee clinic. A person, deliberately, severely damaged by another person. Multiplied by a thousand people, over a thousand wars. And then today, Yusef’s story.

  Months later, when my heart wanted to break upon itself and I was desperate for a small reassurance to hold onto, I remembered that story—the one about the guy who bought the girl at the bar a bocconcini salad.

  Oh yes, but there was that. Humans do that, too.

  9

  THE WEEK BEFORE CHRISTMAS, VANCOUVER received the season’s first big snowfall. It was only a few inches, but everything was transformed by a soft, homogeneous glow. I took public transit to work—the SeaBus, the SkyTrain, a few blocks by foot in snow boots.

  In every other clinic I’ve worked, patient attendance is influenced by the weather. Patients stay away if it’s too sunny, too wet, too slippery, too hot. Not so at the refugee clinic. Refugees have overcome such massive obstacles that inclement weather is a negligible deterrent, I suppose. Sure enough, every patient booked that morning showed up. I was the one who arrived late.

  Between patients, Hani told me about her first snowfall after arriving from Somalia. How unbelievable it was, how beautiful. She put her hand over her chest, trying to convey her amazement. “Everyone who comes to Canada and sees snow for the first time, they never forget that,” she told me in her soft voice. “Never.”

  I enjoyed seeing patients’ responses to seasons in their new country. “We’re celebrating Christmas like real Canadians,” said the first patient, an Iraqi father of two. “I even took my kids to see that white guy in the red suit.”

  The next patient was an Ethiopian grandmother who had arrived in Canada that fall. She lived in Surrey and walked her grandchildren to school every day.

  “Do you celebrate Christmas?” I asked as I peered into her left ear with the otoscope.

  “Not in the past,” she said through the interpreter. “But now that we’re in Canada, we celebrate what Canadians celebrate. So we will have Christmas this year.”

  I was excited for her. “Will you have a Christmas tree?” I asked.

  “What’s that?”

  The third patient was a fifty-five-year-old Iranian woman with diabetes. She was due for bloodwork, and as I filled out the requisition form she asked hesitantly if she could wait a few days before going to the lab. She lowered her voice and said carefully, “Because I’ll be celebrating a . . . holiday this week.”

  “You mean Christmas?” I asked.

  “You too?” she gasped.

  Yes, me and most of the country, and none of us feared persecution for being found out.

  Mid-morning, Yusef and Junah came in. “We couldn’t rebook to come in the New Year,” Yusef explained, “because we had to see you before Christmas to give you this.” Junah pulled a small wrapped gift from her purse. It was a bracelet, a slender silver band with a geometric motif engraved at the centre. I was moved, and not just because they’d braved the icy sidewalks to deliver it.

  Yusef said a little speech, thanking me for what I’d done, the support and the kindness. “You helped us when we were new in the country, in trouble.” I felt professional gratification that they were satisfied with my services; I told them with sincere emphasis that it was my pleasure to care for them. As I ushered them out the door I’d already forgotten their gratitude.

  “That was a beautiful speech,” said Hani after they left.

  I looked at her and I thought, Yes, yes it was beautiful. I’d heard these speeches before, though, thanking me for kindness, and I felt embarrassed to be thanked for dispensing something that cost me nothing: no extra education, no honing of skill, no effort. I’d rather be thanked for diagnostic prowess or a deftly performed procedure. But I extended kindness to patients habitually, with an extra measure when I had nothing else to offer. You shouldn’t need to visit a clinic for kindness, I thought. There should be an abundance of it free for the taking as you move through daily life.

  Later that week, I sat in my doctor’s office, in the chair tucked right next to his desk. This was the first visit that I didn’t sit casually on the exam table with my legs dangling over the side, the first time I hadn’t come in for something routine like a vaccination or contraception, where we’d talk shop and I’d ask
about his daughter, a medical school classmate. This time, I was here about a disastrous ending to a second-trimester pregnancy.

  He knocked on the door, stepped in, and gave me a long, sober look as he slowly closed the door. He sat down. I couldn’t look at him. He sat in silence. Finally, I forced myself to talk, exhausted, crying, despairing. He listened. He leaned over his desk, arms folded on it, looking down. Eventually I glanced at him, and his face was flushed. His eyes were damp. I realized that he was moved by my distress; I was completely taken aback.

  Over the next few weeks, as I celebrated Christmas and rang in the New Year with my family, I repeatedly thought back to our encounter. The memory of him sitting there, seemingly with all the time in the world, fully present, saying little but moved by my situation, was an enormous comfort. His kindness was more dear to me than anything he’d done for our family over the years, even his delivery of my daughter.

  I saw him in follow-up three weeks later. The visit was such a solace that I was certain I was being extended divine kindness; my doctor was the unwitting priest. What a profession! What power! I imagined, longingly, that I could extend the same gift to my patients.

  And I realized with horror that this kindness, which had affected me so profoundly, was the very one that I used unthinkingly in my own practice, that I dismissed as a personality trait, a last resort for patients for whom I had no medical therapy to recommend. I had been wielding something powerful without any respect for it.

  Back at work, I was determined to be conscious of what I gave to patients, and to receive what they returned to me. An elderly Congolese patient with severe osteoarthritis had found a French-speaking family physician near her home. She made a short, thankful speech, and this time I didn’t dismiss the gratitude as grossly disproportionate to what I’d done for her. “Every visit, I felt better just to see you,” she said. She hugged me; I felt very slight. She pressed her cheek against mine, and I could feel and smell her hair. “Don’t forget me,” she said through the interpreter. “Come visit my home.”