The following is an excerpt from Your Heart Is the Size of Your Fist, a memoir by Dr. Martina Scholtens recalling ten years working at BC's only clinic with a mandate to provide initial health assessment and primary care for refugees. The Bridge Refugee Clinic is slated to "ramp down" next month as a new East Vancouver facility takes over recent migrant patients. In this passage Dr. Scholtens reflects on the ethics of sharing others' trauma and her fight to keep the clinic's trauma program open.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.***The clinic lost the federal funding for its trauma program, a critical service for refugees who had experienced terrible events. I was dismayed by the decision, worried for my patients' well-being, and frustrated by the dismissal with which mental health services so often seemed to be treated. I wrote an appeal for its restoration. I worked on it for a week, in the evenings, after the kids were in bed.I began the article with a litany of horrors that I'd seen at the clinic. I knew the names of everyone I described.I've seen an Iraqi mother disabled by a car bomb, and a journalist who was tortured with electrocution in an Iranian prison. I've cared for a Somali family whose newborn babe was flung to the ground and killed by rebel fighters, and Congolese women who were forced to watch the executions of their husbands and sons. I've met Afghani and Pakistani women who were threatened with acid or death as they walked to school or work.
I appealed to empathy:And still I watch as resilient and resourceful patients find a home, learn English, and seek employment. But for some, the trauma they have suffered continues to torment them. They relive horrific events through nightmares and flashbacks. They experience continuous fear, mistrust, and hopelessness. Sirens, police, or loud noise trigger panic. Psychological pain manifests as crippling physical symptoms. They mourn for and worry about family left behind. I see children who hurt themselves, mothers crumpled by shame for being raped, and fathers who cry when left alone.
I appealed to pragmatism:Someone in that state cannot learn a new language, gain employment, or develop social networks. Adjustment to life in a new country is challenging enough when attempted with optimism and energy; it is next to impossible for someone whose psychological reserves have been completely drained.
These patients require intervention to achieve a level of peace necessary to function. Medication offers some benefit, as does primary care, but connecting the patient with a trauma counsellor is essential. Counselling enables the patient to process past events, achieve respite from psychological pain, and move forward with life.
I've depended on Vancouver's trauma counselling services for my patients, and my colleagues and I are now forced to cobble together treatment plans as best we can from the limited resources that remain.
I voiced my frustration at mental health getting short shrift, again:Mental health should not be an add-on, the icing on the cake of medical care. It is foundational to the care of the patient. Stabilizing mental health ought to precede, or occur alongside, diabetes management, hip replacement, and prenatal care—not act as an optional part of patient care to be tackled at the end of the list, should there be leftover resources.
The word patient has its roots in the Latin patiens, meaning one who suffers or endures. That is what I seek to do as a physician at a refugee clinic: to relieve suffering. With this population, I need mental health services to do it.
I submitted the article to two national newspapers. There was no response. I widened the net, sending it to local papers, news blogs, and medical journals. Only one deigned to reply, with a polite rejection.I couldn't believe it. Was it poorly written? Was the issue too narrow and specific? Or—and this idea upset me most of all—did the editors know that it would bore the Canadian public? The lack of interest in publicizing the issue was a stinging second blow.Excerpt and photos reproduced with the permission of Brindle & Glass.Follow Dr. Martina Scholtens on Twitter. 