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The need for compassion

Dr. Alana Hirsh reflects on her journey into addiction medicine, and why self-love can go a long way toward helping others

Dr. Alana Hirsh is pictured in the Downtown Eastside of Vancouver, British Columbia on August 31, 2016.

Dr. Alana Hirsh is pictured in the Downtown Eastside of Vancouver, British Columbia on August 31, 2016.

Ben Nelms/for The Globe and Mail

In the discussion about Canadian drug policy, the unspoken question is: why should we take care of drug addicts? I have had to ask myself this because my job is taking care of people with drug dependence and mental illness in the Downtown Eastside, Vancouver’s notoriously drug and disease-ridden inner city. What does society gain from assisting people who engage in illegal activity, who bring their diseases, and, with increasing prevalence, their death, upon themselves?

I am a McGill and UBC-trained family and emergency physician, and have practised in Canada, the United States, and West Africa. I have delivered babies, treated trauma victims, managed chronic disease, and comforted dying people. And, the truth is, in spite of having had my prescriptions forged, my car broken into, having been threatened and lied to, I enjoy, and feel privileged to treat people afflicted by drug dependence. Drug addicts are my favourite patients.

I stumbled into addiction medicine during a period of disillusionment in my medical education. I was leaning toward specializing in plastic surgery, and had arranged to do my family medicine rotation in Vancouver, mostly for the chance to explore the West Coast. I discovered on my arrival that the doctor I was shadowing worked mainly with pregnant heroin addicts. Sometimes he just sat me in a room with them: “Ask her to tell you her story,” he instructed.

Josie was 16 and pregnant. She had long brown hair and a childish, angelic face. She came from Winnipeg, where there was a warrant out for her arrest. The only person she knew in B.C. was her boyfriend, the father of her child. She was on a methadone program, but was giving half of her dose to her boyfriend to keep him off heroin (he was unable to get a doctor). As a result, by midnight every night she would experience terrible withdrawal symptoms. Withdrawal has been described to me by addicts as “feeling like you are going to die,” and the physiologic effects of it actually did put her fetus at risk of death. So she would sell her body to get money for drugs. She had no family to turn to – her mother had been shooting her up with heroin since she was a baby. She was so skinny – only 106 pounds in her seventh month – and so desperate. “Man, don’t ever do heroin,” she advised me with a rueful smile. She was a good person, a child, trapped in a horribly addicted body.

Since then, I have listened to hundreds of stories. Debra, born to parents who were addicts themselves, had a father who sold her to his friends for extra cash. Jeff’s mother died when he was nine months old, and his father was an alcoholic who beat him. Ryan’s mother tried to commit suicide four times before he turned 10, once by putting her head in the oven.

N urse Sarah Foster and Dr. Alana Hirsh explain to residents of Vancouver’s Downtown Eastside how to use a Naloxone injection kit during a overdose awareness program on August 31, 2016.

Nurse Sarah Foster and Dr. Alana Hirsh explain to residents of Vancouver’s Downtown Eastside how to use a Naloxone injection kit during a overdose awareness program on August 31, 2016.

Ben Nelms/for The Globe and Mail

I had little in common with these patients. I came from a loving, upper-middle-class family, and my main exposure to drugs during my youth was when the police came to school to disseminate the Just Say No campaign. However, I was raised on my mother’s stories: born on a forest floor in Siberia while her parents fled the Nazis during World War II, enduring poverty and malnutrition during her formative years in a displaced-persons camp in Austria. I understood that I had won the jackpot in the privilege department. As undeserving as I felt of my privilege, these people seemed equally undeserving of their misfortune.

Not only did working with this population feel meaningful, it was fun. In the early 2000s, I volunteered with a group called VANDU: Vancouver Area Network of Drug Users. The first time I entered their office I felt like I was walking in to Theatre of the Absurd – heroin users nodded off around the table, while stimulant users bounced off the walls. But as I sat in the corner and observed, I was humbled and impressed as they stuck to an agenda addressing compelling issues: a health network they were forming to do alley patrols and needle exchanges, a protest they were planning to bring attention to the need for safe injection sites. They gradually became my most formidable instructors in public health and grassroots advocacy.

Their methods reflected the candour and compassion I came to expect from drug users. When a member who had been kicked off the board of directors requested to rejoin the group, it was suggested that they go around the table and have each member say how they felt about it. “Larry, you can’t ask girls for sexual favours in exchange for a clean needle,” one explained. I marvelled at the no-BS approach – if only such transparency existed in all groups.

They challenged me to reassess my perceptions of right and wrong. They asked me to steal supplies like Band-Aids, gloves, gauze, and needles from the hospital, and to supervise the illegal safe injection facility (SIF) they were starting (at the time the Canadian government still opposed SIFs) – a room with a single bathroom where users could inject themselves. Concerned for my reputation and license, I bought myself time by suggesting that I do some research first. After studying the literature, which showed evidence of morbidity and mortality reductions with SIFs, and having dealt with the consequences of unsafe drug use among my patients (HIV, hepatitis, severe skin infections, heart infections, overdose etc.), I realized that it would be unethical not to provide this service for people. They helped me see that just because something is a law does not make it right. Years later, the government confirmed their prescient public health measures by opening Canada’s first legal SIF in Vancouver.

Hirsh holds a Naloxone injection kit during a overdose awareness program.

Hirsh holds a Naloxone injection kit during a overdose awareness program.

Ben Nelms/for The Globe and Mail

Amidst the suffering, I witnessed great capacity for community and relationship. Mary was a sex worker and lived in a bedbug-ridden hotel in the Downtown Eastside. Despite her outwardly depressing life, she was a ray of sunshine. Her short blond hair tufted out like a baby chick, and she had a little girl’s voice and mannerisms. “Doctor Alana!” she would happily shout down the hallway when she saw me, and would run over excitedly to hug me or share news. She always thanked me for coming to the office: “It’s just so amazing of you to work with us, we love you so much!” She died of AIDS in her early 40s. At her funeral, a young transgender woman cried, “When I had nowhere to go, she took me in. She taught me how to wear makeup. She was like a mother to me.” For many who have never felt welcome anywhere, the Downtown Eastside is a place where they feel accepted.

The first time I felt parallels between my life and those of my patients with addiction issues, I was in my late 20s, going through a difficult breakup, unsure of the future. One day I looked at my schedule and found that I was working three jobs, and I had booked myself to work 29 out of 30 days. I couldn’t face my pain, so I was drowning it in my work. My patients echoed my own thoughts, “I just feel like such a failure,” and I began to resent their relapses. I left my practice and dove into an Emergency Medicine fellowship. Fast paced, not a moment to spare, saving lives, no time for weakness – the perfect field for a doctor avoiding introspection.

For so many drug users, whose stories of trauma and neglect often began in utero, and who often have untreated mental illness, drug use begins as a reprieve from suffering. Years later, my own coping strategies of escapism and perfectionism had helped me to achieve the “perfect life” I had dreamed of: I had an amazing husband, two beautiful children, and a dog, lived in a beautiful home, and worked as an ER doctor. But just as the drug user’s solution eventually becomes their downfall, so my efforts to be successful caught up with me. The stress of multiple moves between countries, life changes, sleep deprivation from shift-work and babies, and a job that left no room for weakness took a toll. By the time I was diagnosed with post-partum depression after my second child, I had been experiencing anxiety and sadness for at least a year, taxing my marriage, distancing me from friends, making work an exercise in exhaustion. It took me too long to seek help, because I was ashamed. To not be enjoying my beautiful life, to not be not coping better with the stress it entailed, to be suffering from a disease that I learned I had my own stigma toward.

According to writer and addiction doctor Gabor Maté: “We lack compassion for the addict precisely because we are addicted ourselves in ways we don’t want to accept and because we lack self-compassion.”

A view of a overdose awareness program in Vancouver’s Downtown Eastside.

A view of a overdose awareness program in Vancouver’s Downtown Eastside.

Ben Nelms/for The Globe and Mail

When I finally admitted that I needed help, I was ushered into the arms of incredibly supportive and effective care by the medical community. The most surprising thing I experienced when I opened up to my friends and colleagues about my diagnosis was how often they responded by sharing their similar struggles. Some were being treated, some were afraid to ask for help, many were self-medicating. Medical literature suggests that physicians may have higher prevalence of depression than non-physicians. In the United States, about one physician dies by suicide every day.

Self-improvement is noble and what we all strive for, but are we only loveable and worthy if we change? What if changing requires self-love?

I met Debra, who I mentioned above, in her home many years ago, when I visited her with a social worker. Formerly a hard-core injection drug user, she was off all street drugs, living in an apartment out of the DTES, and had recently been granted custody of her child. I asked her what had made her change. She told me how, one day, when she was working the streets as a prostitute, a john assaulted her in an alley. She was so beat up that she was confined to her apartment and couldn’t turn tricks. But she was still addicted to drugs, and needed money to support her habit. So, from her room, she started cutting hair for people. One day she was well enough to go downstairs, and the lady who worked at the fruit stand told her, “You know, you have a real talent for haircutting.” “That moment,” Debra told me, “was the first time in my life that I saw myself as something other than what my father told me I was: a … whore. Suddenly, I was more. I was a hairdresser.” It was the start of a miraculous transformation.

My own effort to practise self-compassion contributed to my husband and I moving our family back to Vancouver from the United States a year ago, closer to family, to socialized medicine, to nature. I found myself back in the DTES, working at a similar job to what I did before practising as an ER doctor, with people who have difficult lives, challenging dependencies, and mental illness. When I work with them now, I don’t just see people who are suffering, I see myself, and all of us: human and fragile and needing support to thrive. And I do not feel ashamed of this. I feel connected. I feel freed.


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