Your Heart is the Size of Your Fist

by Martina Scholtens

  When I saw her next, her viral load had plummeted from 16,000 to 250 copies/mL.

  “Praise God,” she said when I gave her the good news. “Thank you, Jesus.”

  And then, after an appropriate pause, “Thank you, Dr. Scholtens.”

  26

  “DO YOU THINK YOU’LL RETURN to journalism?” I asked Yusef. “Once your English has improved?”

  Through the Resettlement Assistance Program, the Haddads received federal funding for their first year in Canada, while they settled into their community and learned English. The family lived on $1,350 a month. Now that the first year was almost over, Yusef was expected to find employment.

  “My English will never be good enough. I will never have the fluency.” He stated this matter-of-factly, almost hiding his sorrow. “First, a job. Then maybe find a better job or work my way up. Every job wants Canadian work experience, though.”

  He was delivering his resume to electronics warehouses on King George Highway and pizzerias in Whalley. Even educated refugees typically started at jobs requiring physical labour and minimal English, such as warehouse work, construction at the new SkyTrain terminals in Coquitlam, or painting houses. I hadn’t often considered the human hands doing the menial work behind the scenes of everyday life, but after my fifty-year-old Myanmar patient found work packing cucumbers into boxes eight hours a day, I thought of her every time I saw neatly packed cartons of produce at the grocery store.

  Six weeks before, Yusef had shown up at the walk-in clinic to request the medication I’d previously mentioned as a potential treatment for post-traumatic stress disorder. I’d given him a prescription for sertraline, with instructions on how to titrate it over the first few weeks. Since then he had waved off any discussion of his symptoms, except to assure me that he was “much better.” He wanted to talk about his job search.

  “Did you bring your medication?” I asked. I encouraged patients to bring all their prescriptions to every visit. The proportion of patients who took them as prescribed approached zero. It was much easier to review medications with the pills in hand than to discuss the small round white pill.

  He pulled a sheet of blister-packed pills from his bag. The days of the week were printed down the left side, and four plastic bubbles ran next to each day, from left to right: BREAKFAST, LUNCH, DINNER, BEDTIME. Patients accessed the pills by punching out the foil at the back of the compartment. Dispensing medications this way improved compliance for most patients, but for newcomers to Canada the system wasn’t necessarily intuitive, especially for patients who read from right to left, as Yusef did in Arabic. I looked over the sheet he handed me. The compartments for the previous few days were empty. A yellow and white capsule and small white tablet rattled in each of the breakfast bubbles for the remaining days of the week. I nodded and passed it back to him.

  If Yusef wouldn’t talk about his mental health directly, I took this new focus on employment as a surrogate marker. It was reassuring. Freud suggested that two hallmarks of a healthy life are the abilities to love and to work: lieben und arbeiten.1 I considered work not just a marker of health but a means to achieve it. Aside from the obvious benefits of income and extended health insurance, employment provided dignity, structure, and a social network. It offered an opportunity to learn English and distraction from personal difficulties. Work was therapy.

  One of my patients was a twenty-three-year-old Eastern European refugee claimant who worked at McDonalds. She took her job very seriously as she depended on it to pay the legal fees to the lawyer representing her asylum claim. She had to contend with past trauma, the stress of preparing her case, and an unknown future. She folded in on herself under the pressure and kept to herself at work.

  At the start of her shift one morning her manager told her, “I need to talk to you at the end of the day.” Her heart sank. The day dragged on, and when she finally met with her boss that afternoon, her fears were confirmed when he began, “Your co-workers have approached me with some concerns. They’ve noticed that you seem worried and withdrawn, that you don’t join in when they’re joking around and having fun. They want to know if there’s anything they can do to help you feel more relaxed.” No prescription could compete with a thoughtful manager and supportive group of coworkers at a fast-food restaurant.

  “I brought mail,” Yusef said now. He unclipped his satchel and pulled out a bundle of envelopes. This was not unusual. Patients often brought me mail that confused them, especially government and legal letters. I had mixed feelings about this. Reading someone else’s mail felt voyeuristic, an intense breach of privacy. But it often included information on medical appointments or health insurance, and I was grateful for a chance to intercept these.

  “This one is from TB Control,” I said, refolding the pink tissue sheet and reinserting it into the envelope. “Your chest X-ray was clear and you don’t need to go back.” Yusef made a note on the envelope in Arabic.

  “This one confirms that you’re enrolled with British Columbia’s Medical Services Plan. Keep it for your records.”

  The third letter was a fare infraction notice from TransLink. “This is a fine for riding SkyTrain without a ticket,” I said.

  “I thought I would pay the conductor on the train.” SkyTrain stations did not have ticket turnstiles. I could understand how he might have moved with throngs of commuters with monthly passes down the stairs of King George Station onto the platform, unaware that he had to purchase a ticket from the machines off to the side at the station entrance.

  “There is no conductor. You have to purchase a ticket before getting on the train,” I said. “This fine is for $173.00.” Yusef asked me to repeat this, twice. It was an inconceivable amount to him. I read the fine print. The ticket could be disputed within fourteen days. The notice was stamped a month previous.

  “I’ll write a letter on your behalf,” I said, turning to my computer. “You can bring or mail it to the address on the letter.” Typing rapidly, I explained his error, his situation, his income. I asked for mercy, for a reduction or waiving of the fine. Yusef waited patiently, appreciatively. I didn’t go to medical school to read mail for people and petition TransLink to forgive fines, but it was these practical interventions that seemed to mean the most to patients.

  I’d been asked before by confused patients if I was a social worker. No, but I’m going to address your homelessness, finances, or food security first, everything else second. Pulling an extra $200 from this month’s meagre budget would impact Yusef’s health, whether by increasing tension in the household, reducing the grocery budget, or restricting his ability to pay the bus fare to come to the clinic or attend job interviews.

  I signed the letter, handed it to Yusef, and wished him luck. He was grateful, but I couldn’t help wondering if a simpler solution would have been to quietly pay the fine myself.

  Sometimes I fantasized about anonymously mailing patients an envelope stuffed with cash. I imagined the relief that such a windfall could give, although a random wad of hundred dollar bills arriving in the mail could be construed as ominous. I couldn’t do a mail-out to my entire patient roster, so I’d have to be selective about the recipients, and that was ethically fraught. Financial dealings with patients violated the codes of the College of Physicians and Surgeons of BC, of course. I pictured the write-up in the back of its quarterly newsletter, in the Disciplinary Actions section. Then again, a doctor slipping money to her patients might be a welcome break from the usual stories of fraudulent billings and sexual misconduct.

  I resisted the temptation to give patients money. The closest I came was when I diagnosed a Sudanese musician with depression. I knew that what he needed more than any prescription or counselling was a piano. I saw a beautiful one at the thrift store and considered having it delivered to him, benefactor unknown. He lived in a fourth-floor walk-up, though, and I gave up the idea when I considered the delivery logistics. I made the right decision, per my professional regulatory body. I’m not sure my pati
ent would agree. That piano might have saved a life.

  In his book Walden, Henry David Thoreau notes that our money goes first to meeting the basic needs of warmth, shelter, food, and clothing.2 He marvels that once those needs are met, rather than turning our attention to more interesting and important issues, we devote ourselves to attaining bigger shelter, finer food, and a more fashionable wardrobe. I thought of this often, as I witnessed extremes of wealth and poverty in my professional life.

  I worked in one of the least lucrative corners of medicine. I didn’t own a condo in Whistler or take the kids to Europe in the summer; we drove a Honda minivan and our kitchen fixtures were from the seventies. But I had more than enough—enough to purchase an Eames chair, an iconic bent plywood piece with a broad curved seat set low to the ground. It was delivered that fall with a Herman Miller certificate of authenticity. It was the first piece of fine furniture I owned.

  The next day at the clinic, as I gave a young mother instruction on how to access the Food Bank, the beautiful chair came to mind. It was worth the equivalent of three or four months of groceries for her family. As I left the clinic on my lunch break to get a sandwich from Terra Breads, I noticed a colleague’s Audi A7 in the clinic parking lot. It made the purchase of the chair seem reasonable, briefly. It made the disparity of wealth in society seem enormous.

  At the bistro, I paid $8.60 for a grilled asiago cheese sandwich on sourdough bread and $3.00 for an Americano. My lunch would be a financial indulgence for every patient I’d seen that morning. In fact, most of my life was lived in relative luxury: I never ran into patients at my usual out-of-office haunts—the Mt Seymour ski hill, the Nutcracker at the Queen Elizabeth Theatre, the upscale Pidgin Restaurant.

  When I did, it was jarring. Deep Cove is a tourist attraction. Mountains hulk over the seaside village, centred on a one-street strip lined with bistros and art galleries that dead-ends onto a stunning viewpoint of the cove. When I see visitors admiring the view, I feel as proud as if I’d created it myself.

  Every second night, I run. I run through the woods, mindful of tree roots, cougar warnings, and owls that swoop in the dusk. I run along the waterfront, past the kayak rental, the dock, and the red lifeguard chair on its long thin legs. While running that stretch I can never resist swivelling my head to the right, admiring the little harbour golden in the evening light, and the glittering green jetty wrapping around it. I loop back home through quiet back lanes.

  Running makes me feel like an animal in the most wonderful way. My work is relational and cerebral, but running reduces me to a biological creature, moving, breathing, sweating. I flop onto the grass at the beach and feel my ribcage thudding against the damp earth. I am a living creature that will die. But not just yet.

  One evening as I pounded past the kayak rental centre, I came across Yusef kneeling on a prayer mat on the beach. His eyes were closed. I had no idea what etiquette dictated in this situation. Should I wait and greet him? I decided to continue. A hundred metres later I saw Junah, Nadia, and Layth approaching from the dock. They saw me before I could sprint away.

  I was wearing a purple sports bra with a light blue running tank, spandex tights, and pink Nikes. My hair was pulled back in a sweat-soaked headband. When I saw that they recognized me, I stopped and pulled out my earbuds. I hoped my attire wasn’t offensive to them.

  They looked extremely interested in what I was doing, and formed an attentive half circle around me. “You live here, Doctor?”

  “Yes!” I gestured at the treed point forming the south curve of the cove, studded with houses hanging onto cliffs.

  “So beautiful!”

  “Yes. It is.” Sweat trickled down my bare, freckled shoulders. I felt exposed.

  “Have a good night, Doctor.”

  I jogged off, heading for home with the sun slanting through the cedars and raindrops in white relief in the flare. At least I was modelling healthy activity, I thought. Although when I’d discussed exercise with the Haddads in the past, I’d learned that they couldn’t afford athletic shoes.

  27

  IOWA CITY HAD FRAT HOUSES, American flags hanging over front porches, and bunnies running across lawns. The place was unpretentious and friendly. I was in town for a narrative medicine conference, three days of immersion in words and ideas at the Carver College of Medicine.

  “Take a year to read forty novels and one hundred short stories,” the first speaker advised us. “You’ll have the equivalent of an MFA.” The idea seemed to hold universal appeal for the audience. We represented everything from pediatric cardiology to social work to public health, but we all loved to read and write.

  “Physicians ought to write,” said another lecturer, physician-writer Dr. Louise Aronson, “for three reasons: to reflect, to memorialize, and to advocate.” This mirrored physicians’ triple obligation to self, patient, and society, she suggested. I felt convicted. I had done the first two tasks unprompted, for years, but I had little interest in the third.

  The advocates I’d encountered struck me as bitter and shrill. Social justice felt like a fad, something to which people flocked to feel morally superior. I was an introvert with no political savvy. I didn’t want to publicly champion a cause. I just wanted to see patients in my exam room, with the door closed, during office hours.

  I admired religious and medical pragmatism, though, and advocacy for my patients fit with both. My patients were vulnerable. They were rendered effectively voiceless, either by a language barrier or by terrible personal experiences with protests. When federal health insurance for refugees was slashed months after the Iowa conference, I was in a unique position to see what the cuts looked like on the ground. They looked awful: unfair, unsafe, impractical, and short-sighted. Clearly someone had to speak up. I realized, with some reluctance, that that someone was me.

  I wrote an editorial, urging British Columbia to fill in the gaps for refugee health coverage. This time, I followed the advice that Dr. Aronson had given at the conference: Humanize someone who is unlike the reader. Make it personal. No jargon. No more than three pieces of data. Know what you want.

  Leila is a thirty-four-year-old Iranian woman with asthma severe enough that it has landed her in the intensive care unit on two occasions. Her asthma is well managed now, after years of having her medications tweaked by her doctors in Tehran. She rummages in her purse and lines up three inhalers on my desk, each with a different coloured cap, labelled in Farsi script. She needs a refill.

  There’s one problem. She’s a refugee claimant in British Columbia.

  The Interim Federal Health Program, funded by Citizenship and Immigration Canada, has provided limited, temporary health insurance to refugees since 1957. The program has recently been slashed. Refugees are now stratified by category, status, and country of origin, and health-insurance packages doled out accordingly. The lucky ones get close to the original coverage for their first few months in the country. The unluckiest get care only if they put Canadians at risk.

  Leila arrived in Vancouver last month and has a hearing date in a few weeks. She has IFH coverage, but it excludes all medications. IFH will pay for any number of emergency room visits, an ICU admission, and a consult by a respirologist but it will not cover a Ventolin puffer.

  There’s a small supply of medication in our clinic cupboard reserved for emergencies. I give her two puffers, which don’t match the lineup on my desk, and a prescription for the original medications. It’s the best I can do. She’ll have to find the money to fill her prescription, somehow, even though she’s told me that when the family travels three SkyTrain fare zones to the clinic, they eat less for dinner. Maybe a church group will help her, or there’ll be a pharmaceutical sample in the cupboard next time. I explain how to call 911.

  Why has the government of BC been completely silent on the issue of health insurance for refugees in this province? It’s time to clean up this mess, even if we didn’t make it. I’m asking our leaders in BC to join the other provinces in com
mitting to ensuring that all refugees have access to care.1

  I recommended some specific measures that the government could take that would improve the situation. The Province newspaper promptly published the op-ed. Next to the article was a picture of me that I thought alarmingly prominent. I felt exposed. I appreciated the support on social media, especially by my academic family at UBC and colleagues working in refugee medicine, but I dreaded the inevitable pushback.

  The next day I read the letters to the editor in response to my article, most of which protested the restoration of healthcare insurance for refugees. Then I shared the responses with my kids. They had proudly brought the article to school, and I thought that they ought to see the other side of speaking up.

  “Here’s what Andy Baker of Chilliwack had to say,” I told them. They waited expectantly. “‘Dr. Martina Scholtens’ op-ed is, to put it mildly, disgusting.’”

  Saskia’s jaw dropped. “But Mom! Did anyone like it?” This wasn’t about being liked, I told them. It was about making people pay attention. And the next day Terry Lake, the Minister of Health, wrote in to the Province to respond. He defended the existing system: “The B.C. government takes its humanitarian responsibilities seriously. The first priority for the health system is always that patients receive the care they need. We will not deny or turn away anyone from essential services in an acute care setting.”

  I hadn’t expected change overnight. Action would take months or years. Bringing awareness to the issue was just the first step.

  A few weeks later, I helped organize the Day of Action healthcare worker protest to be held in Vancouver, a few blocks from Pete’s Yaletown office. “I’ll walk over during my lunch break,” Pete told me the night before. “Will there be speakers?”

  “Yes. Me, for one,” I answered.

  “You’re kidding.”