on washing feet and trimming toenails

Today is a day that Christians around the world recognize as Maundy Thursday. 

It's the day leading up to Good Friday.

It's the night where Jesus had "the last supper" with his disciples before he was to die. It's also the night where Jesus stopped the meal to wash the feet of his disciples, ending with a haunting command: "So if I, the Master and Teacher, washed your feet, you must now wash each other’s feet."

~~~

There is a patient in the jail I care for. He is four decades my senior, and generally unpleasant.  Our visits follow a typical trajectory: he tells me which abusable medications he would like; I explain why they are unsafe and why I will not be prescribing them. He then proceeds to yell, insult, and curse. At the end of our most recent visit, I asked if there was anything else I can do for him. "Can you cut my toenails?" 

When Jesus talks about blessing those who curse you, I never pictured trimming the gnarly mycotic toenails of someone who cursed me. But that was what happened that day. 

~~~

A couple weeks ago, I saw a patient who I hadn't seen in over six months; he had recently been rearrested. He came in grumpy with a litany of complaints and requests. He concluded the diatribe with "And I need my toenails cut." I asked who usually cut his toes - he said I did. I flashed back to six months ago when I had in fact cut his toenails. It had been a slow clinic that morning, so I let him sit and soak his feet while I dug for what our nurse calls the "hedge cutters" then managed to not vomit while trimming down some of the grossest toes I'd ever seen. All the weight he had gained in jail made it hard to reach his feet; the diabetes had blunted the nerves at his feet and increased the risk that he could cut too close and not feel it; the years of homelessness left his feet worn. 

This day, however, unlike six months ago,was chaotic and busy, and I did not have the extra twenty minutes to offer a pedicure. But it echoed in my head - if I didn't do it, who would? So I moved him to another room to soak his feet while I moved on to the next patient, then brought him back in as I tried not to gag as I again chipped away at his nails with the heaviest pair of nail cutters we had. By the end, he had softened; all the anger he walked in with was gone, and he actually thanked me.

Later that same morning, a man who has been in our jail for more than half a decade sat down on my exam table. We finished talking about his health issues, and I ended as I always do: Is there anything else I can do for you?  Of course he answered: "Can you help me cut my toenails?"  I could see he one toenail poking through his sock. So we soaked his feet and pulled out a clean pair of "hedge cutters," pulled up a stool, and started trimming. At the end, he looked me in the eye and said thank you. 

~~~

When Jesus stopped dinner to wash the feet of his disciples, I don't know if their toes were as gross as the three sets of toes mentioned above - but I'm guessing they weren't too far off.  Yet he still ends by telling the disciples to wash each others' feet. 

Elsewhere in the Bible, Jesus says whatever we have done for these least of these, we have done for him. In that parable, he lists things like visiting him in prison, offering water when he was thirsty, feeding him when he was hungry.  The list doesn't include trimming his toenails when they were long and twisted and gnarly - but it maybe could have been included.  

Somehow in those moments of patiently trimming the twisted toenails of my patients, the anger and hate they came in with somehow changed to gratitude - simply by having their toenails cut.  Because in those moments that make my clinics run late and in the toes that make my stomach church - somehow a little more love enters the world.  

So just as Jesus bent down to wash the feet of his disciples "because he had come from God and was returning to God," I know too that I am held in love.  In this Easter season, I am reminded again of that love that pushes us to wash feet and trim toenails and offer Love to each other. 

World AIDS Day...again

On World AIDS Day last year, I wrote about how I had told another person they had HIV and reflected on how people's lives continue to be turned upside down by a microscopic retrovirus.

Yesterday, the story repeated itself. Again on the eve of World AIDS Day, I found myself sitting across from a young man inside the jail, telling him he has HIV.   

Today, just like last World AIDS Day, my schedule is filled with people from the forgotten edges of society who are all affected by the same invisible infection. 

Over and over, it feels the same: 
Our social worker, asking if I can double book him in again, even though he missed his last two visits. Of course. Because what if this time is the time he comes. 
Our nurse who does medical intakes for the jail, calling to verify the medications of the person who was just released from jail two weeks ago, back again. 
Our electronic health record, notifying me that she is back in the emergency room, high on meth.

It's the same collection of patients, filtering through the jail to the community, then back into the jai. Their promises to stay sober are often unable to stand against the forces of addiction and disconnectedness. It's the same stories of homelessness and untreated mental illness and the struggle to survive. It's the same journey to find healing and worth when the world seems stacked in the favor of anyone else. 

I traveled back to Africa this year for the first time in over a decade. Rates of HIV are going down and treatment is improving, but I still sat across mothers whose babies were born with HIV. I begged a man who drinks liquor instead of taking his HIV meds to go to the hospital because the x-ray of his chest showed tuberculosis. I listened as a teenage girl told me how it wasn't fair that she got HIV but her younger siblings were spared because preventive medications became available only after she was born. 

~~~

I recently attended a conference where another HIV jail doctor shared the same sentiment I've wrestled with over the past few years of working in correctional settings: that things may not change. That despite how much a patient promises this is their last time in jail, that we will probably see them back in jail. That our words and medical knowledge and kindness may not be enough to overcome all the other forces of brokenness in their lives. That all we have are single moments to speak love to someone. That the best and most holy thing we can do is be there in those moments offering Love.  

We do it again and again - every time someone is booked back into jail or stops taking their meds or relapses on meth or loses their housing or their temper; every time someone misses an appointment and wants rescheduled when it is least convenient; every time it feels like someone is never going to change.  Because there is Love that meets me again and again - so what can I do but offer that same grace? 

~~~  

Just like every World AIDS Day, I offer up a prayer: 
That despite how things may seem the same, despite how broken the world appears - that we may always find reasons for hope and courage to love. 

world AIDS day

Yesterday, I told someone he has HIV. Because somehow, despite 30 years of research and medical advances and prevention methods, there are still 50,000 new infections each year in this country alone and over 1 million people living with the disease. 

By the end of my afternoon clinic inside the jail, I saw 5 more people who are living with the virus.  

One has come back from the brink of death at least three times since the 1980s when he was diagnosed. He somehow lives on. Alcohol and homelessness have made taking his medicines difficult, and his T-cells* have come crashing down again, putting him at risk for those same infections that almost killed him before.

One tells me he is working on the cure for HIV from his jail cell.  Schizophrenia has devastated his mind more than HIV ever could. Jail may be the safest place for him, because at least when he is there, he gets his medicines. 

Another survived lymphoma, as if living with HIV was not enough. 

Two continue to fight the addictions that first led to their infection.

This afternoon, I was at the county's HIV clinic, where I see both my patients who have been released from jail and also other individuals living with HIV in our community: a mother from Ethiopia, her daughter and husband also infected. A young man from Mexico. A young woman from Vietnam. Transgender, gay, straight, people of different colors and different languages, all choosing life and health - even when the path is marked by relapses and depression and hospitalizations and homelessness and discrimination and loss.

So, at the start of Advent and on World AIDS Day, a decade after I returned from Africa, thirty years since the start of this epidemic, and two millennia since the first Christmas, I breathe out a prayer offered up before Hope was born: 

"By the tender mercy of our God,

    the dawn from on high will break upon us,
to give light to those who sit in darkness and in the shadow of death, 
to guide our feet into the way of peace." 
-Luke 1:78-79

*marker of immune function

on changing the world

I wanted to change the world. 

During undergrad, a group of my friends started cooking "downtown dinners" - a weekly collaboration of boiling excessive amounts of spaghetti and warming marinara sauce (or on fancier nights, making minestrone soup). We took the food to a courtyard in downtown Gainesville where those who were chronically homeless tended to congregate. The point of the evening was to talk to those who had come to eat. To hear their stories. To listen. 

Being there was hard. It is tough to take in the stories of how someone becomes homeless. It is tough to face the societal issues that underscore these stories: systemic racism, unequal education, untreated mental illness, substance use, trauma. Each week these stories would come out - sometimes cohesively, sometimes shaped by paranoia, loose associations, and angry outbursts. We would listen.  

I don't think any of us were under the illusion that we were making a difference. After three years of these dinners, little changed in the lives of those we sat beside each week. Miss Mary and her collection of mangy dogs still lived in a decrepit tiny house without running water or electricity. Ed kept pushing his shopping cart full of garbage, telling anyone who listened about his mother who had been stolen.* Even though we knew we weren't changing anything, we still showed up each week with pasta in hand. 

A decade later, I found myself working on Skid Row** in Los Angeles during my HIV fellowship. For a year, I took care of the sickest and poorest people in this country.  Most were not housed; for those fortunate enough to be sleeping under a roof, that housing was generally not stable.  For a year, I followed a panel of patients for whom HIV was negligible in comparison to their daily battles for food and shelter and against addiction and mental illness. At the end of our year, my co-fellow and I reflected on our time there: for almost all our patients, little had changed.  A couple patients managed to secure housing. Many more had disappeared from care, lost in the throws of addiction or incarceration. One was murdered. Most are still in the same struggle simply to survive. But we were there. We fought for them to get the medical care they needed.  We listened to their stories. We let it shape our own. 

Now I work in the wealthiest county in America, where poverty and homelessness remain invisible behind the wealth that saturates the Silicon Valley.  Many of my patients are homeless, or will be once they are released from jail. I know that the thirty minute encounters I have with my patients are never going to be enough to undo the injustices in their lives. I can choose the best medicine and carefully explain their health conditions in terms they can understand. But the reality is they leave their visit with me and return to worlds I can't imagine.  Whatever love and compassion and patience I put into our encounter, it can't undo the crack their mother may have smoked while she was pregnant, or the multiple foster homes they were shuffled between, or the gang that was the first place they felt accepted, or the meth addiction that fuels cycles of incarceration, or the criminal charges that unfairly limit future employment and housing and the right to vote. 

There are millions of places of brokenness in this world, and as Sarah Kay so beautifully puts it: "No matter how wide you stretch your fingers, your hands will always be to small to catch all the pain you want to heal." 

I've stopped wanting to change the world. I still seek out the places that are broken, where injustice seems to have won. I still sit and listen and ask the questions whose answers will break my heart. But I don't go to change anyone, because I can't. I go because God is there. I go to love.  

I got a text this week: you saving the world today? 

Nope, never saving the world. Just trying to be love, and praying that in this world that has gone mad with violence and hate, that Love would be what saves us. 

*his mother had not, in fact, been stolen. We did track her down; she was living in a nursing home, trying to recover from the strain of years of caring for him and his profound schizophrenia. 

**yes, this is a real place. 

offering hope

The most common question I get asked when I am seeing a patient who was just diagnosed with HIV in the emergency department is: am I going to die? 

Over and over, I offer reassurance: this is not a death sentence. 

Even to the sickest of patients, I still reassure: this isn't a death sentence. Throughout this year, I've seen people on the edge of death because of complications from undiagnosed HIV. They have severe pneumonia, brain infections, meningitis, or cancer. A handful have had single-digit T-cell counts (normal is around 1000; AIDS is less than 200), and they still manage to survive. 

Recently, a young man came to the emergency room with severe pneumonia like so many others I have seen this year. He was diagnosed with HIV in the emergency department. His T-cell count was 10. When I met him, he begged me to tell him that this wasn't a death sentence. I reassured him that even people with low T-cell counts can start treatment and live long healthy lives. Nothing suggested he might not survive. But things took a turn for the worse; he died a few days later. At age 38. Within 2 weeks of his HIV diagnosis. 

I felt terrible. Because I reassured him that this wasn't a death sentence. Because by itself, HIV isn't. Even with pneumonia like his, it almost always isn't. For him, it shouldn't have been. I hate when patients are given false hope. I felt like I had lied to him.   

Last week, another patient came in. Instead of pneumonia, he came in because he was confused and weak. In addition to being newly diagnosed with HIV, there was a huge mass in his brain. This time, I knew that the odds of his survival were probably low. Like everyone who finds out they have HIV, he begged me to tell him he isn't going to die. I struggled to find the words. We don't know yet exactly what is in your brain. It's probably cancer, and it's probably not good. But no matter what, we are going to be here and take care of you. He died eight days later. 


Most cases of HIV that are diagnosed in the emergency department are not this severe. Most are people who came to the emergency room for something minor: an abscess, a stomach bug, a cold. Because an HIV test is ordered for everyone, it is discovered. 

In these people who are otherwise well, I struggle with how to offer reassurance without minimizing the realities of living with HIV. Because it isn't a death sentence. Because there are amazing treatment options available. Because most people with HIV live long, healthy lives. Because most people with HIV in this country die from something other than HIV. But it still is a life-changing diagnosis, and those promises of health are contingent upon rigid adherence to a combination of medications. There are still losses to grieve. Life won't be the same. But just because life won't be the same doesn't mean it can't still be beautiful.   

healthcare privilege

The first time she stumbled into our clinic on Skid Row, she was on the brink of death. A huge wool coat hung over her 83-pound frame even though it was 90 degrees outside. Thrush crawled out the corners of her mouth and over her lips. She'd been in the ICU last month; she never finished the antibiotics for the AIDS-related pneumonia she had. Now her cough (and every other concerning symptom possible) was back: 

Her blood pressure was 86/40; there was no choice but to send her to the emergency room. We gave her a liter of IV fluids while waiting on the ambulance to come because we knew she might wait a while to see a doctor once she got to the hospital. The wait to be seen by a doctor at LA County Hospital can range anywhere from 8-36 hours. We hoped that sending her by ambulance might expedite things. Sadly, it was almost 24 hours before a doctor saw her, and 28 hours until the necessary chest x-ray was done. The previous pneumonia was still there, though slightly improved. She was released the following morning after a couple doses of IV antibiotics, back to the court yard on Skid Row where she slept. 

Martin Luther King, Jr. said, "Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane." These inequalities become more glaring when I find myself on the privileged side of healthcare. On the same campus where LA County Hospital sits, half a mile down the hill, is a smaller private hospital. Recently, I found myself having to access their services.

I was sent from my doctor's office to the hospital's equivalent of an emergency room. It was less than ten minutes from when I checked into the emergency department until a doctor saw me. Over the weekend when I felt worse, the on-call doctor sent me back to their emergency room. Within thirty minutes, IV fluids were running into my dried out veins. And two days later, when it was finally clear I had to be admitted, it took under an hour to transfer me from my doctor's office into my room. 

Beyond the speed and access to services, I carry additional privilege: speaking the same language as my doctors, having the knowledge to ask questions about my treatment, and being able to read the prescriptions I was sent home with (and a home to return to). 

I struggle with this privilege. Because there is no reason my patient should wait 28 hours for a chest x-ray, when in that same amount of time, I made it to a room, saw the medicine team taking care of me twice, and watched 17 episodes of Friends on TBS. Though our country is trying to lessen these disparities with things like Obamacare and the expansion of Medicaid, we still have a long way to go until everyone has equal access to healthcare. Until then, I'll keep fighting for my patients to get the care they deserve. 

p.s. - in case you were wondering, my patient is doing great. She is now on HIV medicines, has gained 40 pounds, has been living in a medical-transitional housing unit, and will be getting her own place next month after 28 years of living on the streets. 
and i'm doing much better too. :) 

Christmas candles

The recent losses and outcries for justice in Ferguson and New York hit close to home because twice a week I work in the Los Angeles County jail, caring for men who were fortunate enough to survive their arrests. Most are young black men, who are arrested disproportionately compared with their counterparts of other races. 

I never ask my patients why they were arrested. 
Instead,I ask: what are your goals? 

The answers are humbling:
I'm taking classes so I can keep custody of my son. He's nine months now.
I want to have my own Christmas tree someday.
I'm gonna open my own accounting firm; I only need six more credits to finish my degree. 
I want to be a hairdresser. I have a lot of sisters; I'm really good at doing hair. 
I've never walked on the beach with my friend; I want to do that someday. 

So as Christmas comes, I light candles:
A candle in memory of the lives who have been lost. 
A candle for peace, that there would be racial healing and justice in this country. 
A candle of hope, that these men will get the chance to live out these dreams. 

Wishing you a new year filled with hope and peace. 

you can't give hugs in jail

First, some background: 
The LA County Jail is the largest jail system in the country (and possibly the world). It is made of up 9 different facilities that house 15,000-20,000 inmates at any given point in time. 

Men's Central Jail is one of these 9 facilities. It can house up to 5,000 inmates. It is located on the northeast edge of downtown Los Angeles. Five percent of the inmates in Men's Central Jail have known HIV. I work there 2 days each week providing HIV care.

To enter the jail wards, you have to go through a sallyport (aka cage) - where you enter through one gate, which closes behind you, then wait until the second gate opens into the ward. It's a little intimidating. 

I was given a couple pieces of advice for working in jail:
1. Wear pants. (Pants as opposed to my usual dresses. Not pants as opposed to nothing.)
2. If you get lost inside, don't wander. Just fall to the ground and start shaking. A security camera will eventually see you and send help. (I have yet to need this.)

One of my first patients was a young man who recently moved to LA (as always, details changed to protect privacy). He found out he had HIV a while ago but hadn't seen a doctor yet. Despite violence in his family growing up, he'd come far in life. He was credits away from bachelor's degree and had plans to open his own company. He was well-educated about HIV and what it meant when someone had progressed to AIDS. But that knowledge didn't prepare him for the fact that his infection had gone that far. So this beautiful boy, who I'd already invaded with personal questions and now broke crushing news to, started to cry. Because he hasn't lived a quarter of a century and already has AIDS. Because whatever hope led him to LA has been derailed by incarceration. Because his momma sits across the country and has no idea her son is in jail or that he has been living with HIV. 

In any other setting, I'd reach out and touch him - place a hand on his arm or pat his shoulder or offer a hug. But you can't give hugs in jail. So I willed my eyes to speak what I couldn't communicate with touch so he would know he is not alone. Over and over, I reassured him: this is not the end. things can get better. you can get better. 

He was released the next day. He knows where to find the clinic where I work. I hope he comes. I owe him a hug.  

taking in stories

It's crazy to think it's been more than a month already. There is a lot of HIV in LA. I have spent a lot of time listening. I have taken in a lot of stories.

(billboard on my drive home each day)

The stories start to run together. It's not that they are the same - it's just that there are so many:

A woman who was diagnosed while she was pregnant. She told her oldest child but still doesn't know how to tell the young ones. 

A father who didn't want to spread his cough to his baby girl, so he came to the ER to get checked. Now he asks if it's safe to hug her ever again. (yes, it is.)

A woman who was raped while she was crossing the border. Her child and family are still in Central America; she hasn't told them what happened. 

A grandmother who needed a blood transfusion years ago. 
A traveler from Europe who felt sick during his vacation.
A rapper with big dreams who ended up homeless and addicted to drugs.

People who have fought HIV for years, and people who found out only minutes ago. 

People in good relationships and bad ones. 

People who sleep on the streets and people who live in mansions.
People who laugh and cry and fight for life with a resilience I'll never know. 

A lot of the time, the sorrow of these stories is overwhelming. And despite huge advances in medicine, having HIV is difficult - whether it is the hurt or shame of how it was acquired, or the discrimination that those with HIV still face, or isolation from family, or struggling to break free from the addiction that led to becoming infected, or being unable to work due to illness, or simply having to remember to take medicine every day from now on. I'm still figuring out how to take it all in, how to keep listening, how to keep offering hope. 

"Compassion asks us to go where it hurts, 

to enter into the places of pain, 

to share in brokenness, fear, confusion, and anguish." 

-Henri Nouwen

new job, new pager

I started being on-call for the emergency department this weekend. LA County Hospital(LAC+USC) has a HUGE emergency department. I am told they see 180,000 patients each year (compare to Allegheny General Hospital ED which sees 38,000 patients per year, and Temple that sees 130,000 per year). The wait to be seen ranges from 12-36 hours.

Every patient who comes into the ED receives HIV testing (unless they opt out). When someone is newly found to have HIV, I get called to go talk with the person. Sometimes this involves telling them their diagnosis if no one has told them already; mostly it involves talking about what that diagnosis means and connecting them with our clinic. I think I am a bad luck charm becaues I was called about 4 new patients in the first 24 hours.

Not everyone comes in suspecting that they have HIV; in fact, most don't. They come in with coughs and headaches that have gone on too long, only to find the underlying thing causing their symptoms is not only HIV but AIDS.

My first patient (details changed to protect privacy) was younger than me, but life had been unfair. He'd been living on the streets, earning money however he could - even if that meant doing things he didn't want to do. Drugs made doing these things easier. He suspected for a while that he might have HIV, but couldn't find the courage to be tested until now. After 20 hours of waiting, he had his answer. So at 5am, we sat and talked in a quiet corner of the chronically-overcrowded ED. He spilled out stories of his life; of trauma; of how he wants to live now. We scheduled an appointment at our clinic. He'll start treatment. He'll probably be fine. Or at least his HIV will. Most of what he carries, I can't fix. But I can keep hoping for him.  

(view of downtown LA from LAC+USC)

 

the i-don't-knows

i have answered "i don't know" no less than 286 times this month when asked details about moving.

some have been logistical questions that finally have answers:

where will you be living?

monterey hills (east of downtown LA)

have you packed?

finally, yes.

what will you be doing?

it's an HIV corrections fellowship.

i'll be at LA County Hospital's HIV clinic, the LA county jail, and a clinic on Skid Row.

yes, Skid Row is a real place.

yes, I said the jail.

yes, my mom is nervous.

will you miss pittsburgh?

YES!

a lot of questions are more complex, and i don't have answers. i have no idea what to expect. i don't know what it will be like working in a jail. i don't know what my patients will be like or how i will fill my days. i know data and statistics about hiv and jail and homelessness, but i don't know anyone's stories yet so i feel at a loss.

the good news is, i've done a lot of things before where i haven't known anything other than facts:

i moved to swaziland knowing only the perinatal hiv rate (42.6%) and the number of orphans (100,000 of a national population of one million). what i found were amazing friends like zandi and jabu who taught me what it is to hope.

i worked in alaska for a month at a native alaskan hospital. i knew rates of alcoholism and domestic violence were horribly high, but it wasn't until bruised women shared with me their stories did i start to understand.

so now i start this next adventure with all of my not-knowing, and am waiting for the stories to begin.

"instructions for living a life:
pay attention.
be astonished.
tell about it."
-mary oliver

the end of residency

over and over, i'm breathing out thankfulness.

i made it.

3 years ago, i was assigned five patients.
i didn't know how to enter orders in the computer.
my white coat was still white.
i thought i would only do this for a year.
instead, i fell in love with taking care of patients and decided to stay.

i couldn't leave the place of listening to human stories in exchange for shaping global health policy. i know policy touches communities, but i needed to touch the person in front of me. at the time, it seemed like a huge decision to give up hopkins for a general hospital in a post-industrial city. but i knew i had to stay.

being healthly intern  year was grace; without that year of health, i would have left clinical medicine and entered the world of public health.

it has been anything but easy. four hospital admissions. countless infections. monthly infusions. my sister over and over reminded me "just keep swimming."

so i kept swimming, upstream like the salmon, and i've ended up at beautiful over and over: working in alaska for a month. watching a friend get married in india. listening and being humbled by the patients who trust me with their stories.

and the same prayer i have breathed out countless times over the past three years, whispered under my breath in airplanes taking off over delhi and sitka, to cries from hospital beds when planes left without me:

blessed are you, o lord, who has kept us alive and sustained us,

who has brought us whole to this moment.

residency in iPhone photos

This is where I have spent the last 3 years:

The views from the hospital aren't that bad:

I spent most my time trying to figure out which pager was beeping and waiting on people to return my pages:

I survived off of cafeteria food and graham crackers stolen from nurse's stations:

I looked at way too many of these:

I rarely saw the call room (note the unused bed):

 

I made sure the important orders got in first:

Only once did I ever see the emergency room empty:

There were early morning signouts, greasy post-call breakfasts, and rare chances to sit in the resident lounge:

I had lots of opportunites to wear Indian clothes:

 

I tried my hardest to avoid being a patient: 

And got to I spend a month working in Alaska:

It's been an amazing, exhausting, humbling, tiring, but beautiful 3 years.

Now I'm turning in my pager and my badge because I'm done!

 

a million thanks and then some to my family and friends

for all the love that has carried me through these past 3 years.