Start Reading On the Ragged Edge of Medicine

All too often a day at Burnside Health Center would begin with a melancholy tramp through the heart of Portland. I would leave my car in the cool of early morning near the river that slices the city in two. The parking lot spread out in the shadow of the Morrison Bridge, one of ten bridges that spanned the river in those days. To exit on foot, I passed under the downward slope of a curving off-ramp. Where it came to ground, the ramp made a dank wedge of space, which often smelled of piss and even in summer was spotted with oily puddles. Sometimes, before a chain link fence was installed to keep people out, I could make out blobs of sleeping bags at the farthest reach of the space. Then I would look away, faintly embarrassed, as if I had carelessly glanced into someone’s bedroom.

From there it was a ten-block trek to the clinic. I would head away from the river into downtown, merging with a bustle of suits, portfolios, wingtips, and pumps, umbrellas in winter, shades in summer. I’d pass cafés and more coffee shops than you’d think the market could bear; a magic shop, a Western clothing store, and a business that peddled vintage magazines; a glass and steel office building known as Big Pink, because it was; and a couple of granite-faced edifices with the names of Portland’s forefathers engraved in the stone.

As I passed, I would scrutinize the overhangs, doorways, and parking structures for their merits as places to sleep. Could I squeeze in on the dry side of that drip line? Could robbers, rapists, or thugs spot me in that out-of-the-way corner? Would the north wind whistle around into that recess? Would police or security roust me out of there in the middle of the night? Weren’t these the calculations that people living on the street would make when settling in for the night? The preoccupation was not a happy one, and whenever I caught myself refracting the streets through this particular lens, I’d force my mind elsewhere. I knew too many people sleeping out at night. They were my patients.

The best places to shelter, by my admittedly inexpert survey, were concentrated near the river and, surprisingly, on the skyscraper side of the north-south city divide, Burnside Street. Once I traversed the half-dozen blocks through the commercial core and crossed over Burnside to the north, I found no spots to spend a night beyond the shallow doorways. Here the skyline dropped on average a good ten stories; pea coats and T-shirts replaced the suits; sidewalks became littered with broken glass, smashed beer cans, and the soiled Styrofoam clamshells of fast-food takeout. Once in a while, in the gutter, even less savory items were discarded, like used needles or condoms. Instead of glass, steel, and granite, the structures were brick and wood, some of them dilapidated or boarded up, taverns with no windows, eateries with greasy ones, residential hotels, a shelter, a soup kitchen, and the remnants of a Chinatown in steep decline.

Near the end of the twentieth century Old Town, née the North End, where both the Chinese and African American communities got their start, was between two never-quite-complete attempts at revitalization. A jazz club, import mega-store, and a couple of boutiques were left over from the last one. The next one would bring the Lan Su Chinese Garden, lofts converted to living space for upscale urbanites, and exclusion laws designed to keep habitual drug offenders out of the district.

Two blocks in I would reach Burnside Health Center, a storefront clinic on NW Davis, a street known to be the run of pimps, thieves, drunks, and dope peddlers. Next door stood the Butte Hotel, one of several SROs (single resident occupancy) in the area for lonely, down-on-their-luck folks, mostly men. The old hotel was infested with cockroaches, which streamed over into our space. We knew, because when the exterminators periodically arrived to spray the clinic, they told us that’s where our roaches came from. Two blocks down was Sisters of the Road Café, where a person could get a meal in exchange for work. Burnside Projects (later Transition Projects) ran a shelter and cleanup center five blocks away.

My patients at Burnside (and later, at Westside Health Center, located in the commercial core) were poor and most of them sick to one degree or another. They were of every ethnicity and every imaginable blend. Lots of them slept under bridges, in parks, in their cars, or on their brother’s sofa. Most lived with mental illness, addictions, or both. They included undocumented, disabled, and unemployed workers, sex workers, pensioners, panhandlers, and felons. Not a few of them labored in low-wage jobs. They were veterans of wars both legal and covert. Many of them didn’t speak English; some of them couldn’t read. A distressing number of them were on the streets because they were too cognitively disorganized to access the services to which they were entitled, like Social Security Disability.

The majority had suffered abuse of one sort or another, either as children, adults, or both, at the hands of family, institutions, and states. Some were refugees of war, coming from countries all over the world. Most were poorly educated, though among them was a doctor from Iran, a lawyer from Afghanistan, a nurse from Somalia. Also a musician, a journalist, a contractor, and a professor of physics, all native born and fallen on hard times or bad choices, usually a combination of the two. One said he’d traveled as a personal assistant to Red Skelton, and I believed him. Who would make that up? Most, however, had been poor their entire lives; not much ever trickled down to them. Economic boom or bust, it didn’t matter; their poverty was a given.

They amazed me. They were funny, insightful, and caring in the midst of destitution. They were resilient and incredibly resourceful. Not for a minute did I think I could endure what they did. Far from perfect, they failed on many levels, and the consequences for their failures were severe. They suffered as well from my mistakes.

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I, myself, was a refugee of sorts when I came to Burnside, fleeing a suburban practice. The clinic there was spacious and light and included all the amenities of a modern medical institution. My coworkers were nice. My patients were lovely. Few were particularly sick. And I was terminally bored. I would catch myself watching the clock, the last thing I ever expected out of my advanced degrees in medicine and public health. I was itching to deploy my skills where they were really needed. I hankered for a practice that others would shun.

In 1988 I accepted the job of medical director for Multnomah County Health Department and became responsible for the quality of care delivered at what eventually swelled, over my two-decade tenure, to more than thirty primary care and public health clinical sites. For my part-time practice, I chose Burnside Health Center, located in the heart of Portland’s skid row.

But it would be misleading to imply that I landed at Burnside out of a lust for intellectual stimulation and a desire to serve. I did. But that wasn’t all.

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When we were growing up, my mother always had a “cleaning lady” who came weekly to help Mom maintain a modicum of hygiene and order in our large, three-story home in southwest Portland. Seven of us were a lot to clean up after. One time she hired an African American woman, a “Negro she would have called her in 1953. Mom told the story that I, as a three-year-old, followed the woman around and pestered her incessantly about why her skin was so dark. The woman refused ever to come again. I have no recollection of the incident, but I do remember, as a schoolgirl, becoming entranced with a 1943 photo of my father standing next to a native of the jungle island where he’d been stationed as a flight surgeon for the Navy. The fellow had wrenched his shoulder out of its socket and Dad had maneuvered it back into place. In the shiny black and white snapshot my father towered over the other man, who was so dark I could barely make out his features. His hair was black and curly. He was clothed in what I took to be a short dress and no shoes. I had no idea men like that existed.

I was thoroughly white-bread, an upper-middle-class WASP—white Anglo-Saxon Protestant. At college, during the tumult of the sixties, it became to me an identity that signified the opposite of cultural authenticity and moral authority. It bestowed advantages I had not earned. It had kept me apart from people of color and from those of the disadvantaged classes. It was sort of embarrassing, like something I had to make up for. I no longer felt quite at home in my own skin, among my own people, within the smug circles of privilege.

So it was that some sense of duty and middle-class guilt propelled me to Burnside, motives that can render the heart impure—patronizing and paternalistic. Clinging to the underside of that was the still more unworthy desire for adventure, to get a bit dirty without risk, to venture out where hardly anyone wanted to go. Medical slumming, you could call it. Suffering as spectacle. I see this now with clarity. Back then it was a vague discomfort that I suppressed. I had my self-image to protect.

The patients saved me. They took me at face value, as a doctor who was interested and wanted to help. They commanded my affection and respect. They taught me humility. They drew me in close enough that I could not be the voyeur standing outside and looking in, because I was no longer outside. I’d stepped inside, with them. Not that I ever did or ever could experience the depredations and humiliations of poverty that they suffered on a daily basis. But still, we became allies. We shared objectives. We cultivated the same institutional friends and battled the same bureaucratic foes. It was not, then, a tour of duty; it was no sacrifice to work there.

Over time I became more comfortable working with people whose life experiences were so utterly different from my own. The health department paid close attention to the issues of working across boundaries of culture, language, religion, ethnicity, sexual orientation, or gender identity and how to negotiate those differences with grace and respect. This is not to say that we always got it right. Still, there was an awareness, an openness and intentionality. What was mostly lost or ignored in those sometimes contentious discussions and presentations was class difference. We were lectured only on the culture of (white) poverty, which was interesting, though hardly adequate. Class was an uneasy topic, perhaps because we were all implicated.

I continued to struggle over the years with the problem of class privilege—inextricably intertwined, as it was, with white privilege—and the power dynamic it necessarily introduced into the exam room. I think it was because differences in language, culture, and experience were things to explore and celebrate. There was no justification, let alone joy to be had, in the unconscionable gap in wealth and privilege. It never escaped me that I went home to sleep in a bed and many of my patients went to sleep on the streets.

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These narratives are not about triumph and tragedy. They are about me and my patients, tussling with each other while struggling with the patient’s physical and emotional distress, set in a context where conditions were pretty much stacked against the sufferer. It wasn’t all that easy for me either. You won’t find too many happy endings here. These are not my success stories. What interests us most, of course, is trouble. It is when we are in the grip of trouble, when things do not work out as planned, that we most often discover ourselves. I wrote these particular stories because what happened troubled me and the writing helped to clarify and illuminate. In some cases, it enabled me to forgive myself.

The stories are also reflections about the work of doctoring. The physical, psychological, and intellectual demands. The terrible uncertainties. The confines of the system we work in, with its twists and loops and blind allies, a system neither very rational nor functional, especially not in the outposts that serve the poor, out on the ragged edge of medicine.

I relied a lot on notes I kept about patients over the years. But I’ve reconstructed the dialogue out of my certainly sketchy memory. The timelines are approximate. Nothing happened exactly like it is presented here. Memory isn’t like that. However, I have not strayed from the essential thrust of each story, the dynamics of what happened, and the impact on me and on my patient. It must be further noted that these are my versions of what happened; I cannot claim to know the fullness of the patient’s experience. Still, the stories belong as much to the patients as they do to me. For an hour or for decades, we were parts of each other’s lives.