Dr. Gabor Maté’s new book puts a human face on addiction
As I pass through the grated metal door into the sunshine, a setting from a Fellini film reveals itself. It is a scene both familiar and outlandish, dreamlike and authentic.
On the Hastings Street sidewalk, Eva, in her thirties but still waif-like, with dark hair and olive complexion, taps out a bizarre cocaine flamenco. Jutting her hips, torso and pelvis this way and that, bending now at the waist and thrusting one or both arms in the air, she shifts her feet about in a clumsy but concerted pirouette. All the while she tracks me with her large, black eyes.
In the Downtown Eastside this piece of crack-driven improvisational ballet is known as “the Hastings shuffle,” and it’s a familiar sight. During my medical rounds in the neighbourhood one day, I saw a young woman perform it high above the Hastings traffic. She was balanced on the narrow edge of a neon sign two storeys up. A crowd had gathered to watch, the users among them more amused than horrified. The ballerina would turn about, her arms horizontal like a tightrope walker’s, or do deep knee bends—an aerial Cossack dancer, one leg kicked in front. Before the top of the firemen’s ladder could reach her cruising altitude, the stoned acrobat had ducked back inside her window.
Eva weaves her way among her companions, who crowd around me. Sometimes she disappears behind Randall—a wheelchair-bound, heavy-set, serious-looking fellow, whose unorthodox thought patterns do not mask a profound intelligence. He recites an ode of autistic praise to his indispensable motorized chariot. “Isn’t it amazing, Doc, isn’t it, that Napoleon’s cannon was pulled by horses and oxen in the Russian mud and snow. And now I have this!” With an innocent smile and earnest expression, Randall pours out a recursive stream of facts, historical data, memories, interpretations, loose associations, imaginings, and paranoia that almost sound sane—almost. “That’s the Napoleonic Code, Doc, which altered the transportational mediums of the lower rank and file, you know, in those days when such pleasant smorgasboredom was still well fathomed.” Poking her head above Randall’s left shoulder, Eva plays peek-a-boo.
Beside Randall stands Arlene, her hands on her hips and a reproachful look on her face, clad in skimpy jean shorts and blouse—a sign, down here, of a mode of earning drug money and, more often than not, of having been sexually exploited early in life by male predators. Over the steady murmur of Randall’s oration comes her complaint: “You shouldn’t have reduced my pills.” Arlene’s arms bear dozens of horizontal scars, parallel, like railway ties. The older ones white, the more recent red, each mark a souvenir of a razor slash she has inflicted on herself. The pain of self-laceration obliterates, if only momentarily, the pain of a larger hurt deep in the psyche. One of Arlene’s medications controls this compulsive self-wounding, and she’s always afraid I’m reducing her dose. I never do.
Close to us, in the shadow of the Portland Hotel, two cops have Jenkins in handcuffs. Jenkins, a lanky Native man with black, scraggly hair falling to below his shoulders, is quiet and compliant as one of the officers empties his pockets. He arches his back against the wall, not a hint of protest on his face. “They should leave him alone,” Arlene opines loudly. “That guy doesn’t deal. They keep grabbing him and never find a thing.” At least in the broad daylight of Hastings Street, the cops go about their search with exemplary politeness—not, according to my patients’ stories, a consistent police attitude. After a minute or two Jenkins is set free and lopes silently into the hotel with his long stride.
Meanwhile, within the span of a few minutes, the resident poet laureate of absurdity has reviewed European history from the Hundred Years’ War to Bosnia and has pronounced on religion from Moses to Mohammed. “Doc,” Randall goes on, “the First World War was supposed to end all wars. If that was true, how come we have the war on cancer or the war on drugs? The Germans had this gun Big Bertha that spoke to the Allies but not in a language the French or the Brits liked. Guns get a bad rap, a bad reputation—a bad raputation, Doc—but they move history forward, if we can speak of history moving forward or moving at all. Do you think history moves, Doc?”
Eva prances out from behind Randall’s back. I turn away. I’ve had enough street theatre and now I want to escape. The good doctor no longer wants to be good.
We congregate, these Fellini figures and I—or I should say we, this cast of Fellini characters—outside the Portland Hotel, where they live and I work. My clinic is on the first floor of this cement and glass building designed by Canadian architect Arthur Erickson, a spacious, modern, utilitarian structure. It’s an impressive facility that serves its residents well, replacing the formerly luxurious turn-of-the-century establishment around the corner that was the first Portland Hotel. The old place, with its wooden balustrades, wide and winding staircases, musty landings and bay windows, had a character and history the new fortress lacks. Although I miss its Old World aura, the atmosphere of faded wealth and decay, the dark and blistered windowsills varnished with memories of elegance, I doubt the residents have any nostalgia for the cramped rooms, the corroded plumbing or the armies of cockroaches.
The nonprofit Portland Hotel society for whom I am the staff physician turned the building into housing for the nonhousable. My patients are mostly addicts, although some, like Randall, have enough derangement of their brain chemicals to put them out of touch with reality even without the use of drugs. Many, like Arlene, suffer from both mental illness and addiction. The PHS administers several similar facilities within a radius of a few blocks: the Stanley, Washington, Regal and Sunrise hotels. I am the house doctor for them all.
The new Portland faces the Army and Navy department store across the street, where my parents, as new immigrants in the late 1950s, bought most of our clothing. Back then, the Army and Navy was a popular shopping destination for working people—and for middle-class kids looking for funky military coats or sailor jackets. On the sidewalks outside, university students seeking some slumming fun mixed with alcoholics, pickpockets, shoppers and Friday night Bible preachers.
No longer. The crowds stopped coming many years ago. Now these streets and their back alleys serve as the centre of Canada’s drug capital. One block away stood the abandoned Woodward’s department store, its giant, lighted “W” sign on the roof a long-time Vancouver landmark. For a while squatters and antipoverty activists occupied the building, but it has recently been demolished; the site is to be converted into a mix of chic apartments and social housing. The Winter Olympics are coming to Vancouver in 2010 and with it the likelihood of gentrification in this neighbourhood. The process has already begun. There’s a fear that the politicians, eager to impress the world, will try to displace the addict population.
What makes the Portland model unique and controversial among addiction services is the core intention to accept people as they are—no matter how dysfunctional, troubled and troubling that may be. Our clients are not the “deserving poor”; they are just poor—undeserving in their own eyes and in those of society. To borrow from Dostoevsky, they are “the insulted and the injured.” Virtually without exception, they all look back on—or desperately look away from—childhood histories of severe abuse, abandonment and neglect.
At the Portland Hotel there is no chimera of redemption nor any expectation of socially respectable outcomes, only an unsentimental recognition of the real needs of real human beings in the dingy present, based on a uniformly tragic past. The uncomfortable truth is that most of our clients will remain addicts, on the wrong side of the law as it now stands. Kerstin Stuerzbecher, a former nurse with two liberal arts degrees, is a Portland Society director. “We don’t have all the answers,” she says, “and we cannot necessarily provide the care people may need in order to make dramatic changes in their lives. At the end of the day it’s never up to us—it’s within them or not.”
At a talent evening held by the Portland a few years ago a long-time resident came up to the microphone. He said he didn’t have a poem to recite or anything else creative.”¦What he shared was that the Portland was his first home, the only home he’s ever had. He was grateful, he said, for the community he was part of and he wished his mom and dad could see him now.
“The only home he’s ever had”—a phrase that sums up the histories of many people in the Downtown Eastside of “the world’s most liveable city.”
The work can be intensely satisfying or deeply frustrating, depending on my own state of mind. Often I face the refractory nature of people who value their health and well-being less than the immediate, drug-driven needs of the moment. I also have to confront my own resistance to them as people. As much as I want to accept them, or as much as I do so in principle, some days I find myself full of disapproval and judgment, rejecting them and wanting them to be other than who they are. That contradiction originates with me, not with my patients. It’s my problem—except that, given the obvious power imbalance between us, it’s all too easy for me to make it their problem.
My patients’ addictions make every medical treatment encounter a challenge. Where else do you find people in such poor health and yet so averse to taking care of themselves or even to allowing others to take care of them? At times, one literally has to coax them into hospital. Take Kai, who has an immobilizing infection of his hip that could leave him crippled, or Hobo, whose breastbone osteo-
myelitis could penetrate into his lungs. Both men are so focused on their next hit of cocaine or heroin or “jib”—crystal meth—that self-preservation pales into insignificance. Many also have an ingrained fear of authority figures and distrust institutions, for reasons no one could begrudge them.
“The reason I do drugs is so I don’t feel the fucking feelings I feel when I don’t do drugs,” Nick, a forty-year-old heroin and crystal meth addict once told me, weeping as he spoke. “When I don’t feel the drugs in me, I get depressed.” His father drilled into his twin sons the notion that they were nothing but “pieces of shit.” Nick’s brother committed suicide as a teenager; Nick became a lifelong addict.
The Hell Realm of painful emotions frightens most of us; drug addicts fear they would be trapped there forever but for their substances. This urge to escape exacts a fearful price.
The cement hallways and the elevator at the Portland Hotel are washed clean frequently, sometimes several times a day. Punctured by needle marks, some residents have chronic draining wounds. Blood also seeps from blows and cuts inflicted by their fellow addicts or from pits patients have scratched in their skin during fits of cocaine-induced paranoia. One man picks at himself incessantly to get rid of imaginary insects.
Not that we lack real infestation in the Downtown Eastside. Rodents thrive between hotel walls and in the garbage-strewn back alleys. Vermin populate many of my patients’ beds, clothes and bodies: bedbugs, lice, scabies. Cockroaches occasionally drop out from shaken skirts and pant legs in my office and scurry for cover under my desk. “I like having one or two mice around,” one young man told me. “They eat the cockroaches and bedbugs. But I can’t stand a whole nest of them in my mattress.”
Vermin, boils, blood and death: the plagues of Egypt.
In the Downtown Eastside the angel of death slays with shocking alacrity. Having worked in palliative medicine, care of the terminally ill, I have encountered death often. In a real sense, addiction medicine with this population is also palliative work. We do not expect to cure anyone, only to ameliorate the effects of drug addiction and its attendant ailments and to soften the impact of the legal and social torments our culture uses to punish the drug addict. Except for the rare fortunate ones who escape the Downtown Eastside drug colony, very few of my patients will live to old age. Most will die of some complication of their HIV or Hepatitis C or of meningitis or a massive septicemia contracted through multiple self-injections during a prolonged cocaine run. Some will succumb to cancer at a relatively young age, their stressed and debilitated immune systems unable to keep malignancy in check.
One constant at the Portland Clinic is pain. Medical school teaches the three signs of inflammation, in Latin: calor, rubor, dolor—heat, redness and pain. The skin, limbs or organs of my patients are often inflamed, and for that my ministrations can be at least temporarily adequate. But how to soothe souls inflamed by the intense torment imposed first by childhood experiences almost too sordid to believe and then, with mechanical repetition, by the sufferers themselves? And how to offer them comfort when their sufferings are made worse every day by social ostracism—by what the scholar and writer Elliot Leyton has described as “the bland, racist, sexist and ”˜classist’ prejudices buried in Canadian society: an institutionalized contempt for the poor, for sex trade workers, for drug addicts and alcoholics, for aboriginal people.” The pain here in the Downtown Eastside reaches out with hands begging for drug money. It stares from eyes cold and hard or downcast with submission and shame. It speaks in cajoling tones or screams aggressively. Behind every look, every word, each violent act or disenchanted gesture is a history of anguish and degradation, a self-writ tale with new chapters added each day and scarcely a happy end.
What draws me here? All of us who are called to this work are responding to an inner pull that resonates with the same frequencies that vibrate in the lives of the haunted, drained, dysfunctional human beings in our care. But of course, we return daily to our homes, outside interests and relationships while our addict clients are trapped in their Downtown Gulag.
Some people are attracted to painful places because they hope to resolve their own pain there. Others offer themselves because their compassionate hearts know that here is where love is most needed. Yet others come out of professional interest: this work is ever challenging. Those with low self-esteem may be attracted because it feeds their egos to work with such powerless individuals. Some are lured by the magnetic force of addictions because they haven’t resolved, or even recognized, their own addictive tendencies. My guess is that most of us physicians, nurses and other professional helpers who work in the Downtown Eastside are impelled by some mixture of these motives.
There’s another factor in the equation. Many people who’ve worked in the Downtown Eastside have noticed it: a sense of authenticity, a loss of the usual social games, the surrender of pretence—the reality of people who cannot declare themselves to be anything other than what they are.
Yes, they lie, cheat and manipulate—but don’t we all, in our own ways? Unlike the rest of us, they can’t pretend not to be cheaters and manipulators. They’re straight-up about their refusal to take responsibility, their rejection of social expectation, their acceptance of having lost everything for the sake of their addiction. That isn’t much by the straight world’s standards, but there’s a paradoxical core of honesty wrapped in the compulsive deceit any addiction imposes. “What do you expect, Doc? After all, I’m an addict,” a small, skinny forty-seven-year-old man once said to me with a wry and disarming smile, having failed to wheedle a morphine prescription. Perhaps there’s a fascination in that element of outrageous, unapologetic pseudo-authenticity. In our secret fantasies who among us wouldn’t like to be as carelessly brazen about our flaws?
“Down here you have honest interactions with people,” says Kim Markel, the vivacious, spike-haired nurse at the Portland Clinic. “I can come here and actually be who I am. I find that rewarding. Working in the hospitals or in different community settings, there’s always pressure to toe the line. Because our work here is so diverse and because we’re among people whose needs are so raw and who have nothing left to hide, it helps me maintain honesty in what I do. There’s not that big shift between who I am at work and who I am outside of work.”
Amidst the unrest of irritable drug seekers hustling and scamming for their next high, there are also frequent moments of humanity and mutual support. “There are amazing displays of warmth all the time,” Kim says. People tend to each other through illness, report with concern and compassion on a friend’s condition and often display more kindness to someone else than they usually give themselves.
It is invigorating to operate in an atmosphere so far removed from the regular workaday world, an atmosphere that insists on authenticity. Whether we know it or not, most of us crave authenticity, the reality beyond roles, labels and carefully honed personae. With all its festering problems, dysfunctions, diseases and crime, the Downtown Eastside offers the fresh air of truth, even if it’s the stripped, frayed truth of desperation. It holds up a mirror in which we all, as individual human beings and collectively as a society, may recognize ourselves. The fear, pain and longing we see are our own fear, pain and longing. Ours, too, are the beauty and compassion we witness here, the courage and the sheer determination to surmount suffering.
Excerpted from In the Realm of Hungry Ghosts. Copyright © 2008 Gabor Maté. Published by Knopf Canada. Reproduced by arrangement with the Publisher. All rights reserved. Expect more on this topic in the next Straight.