Class of 2017
In the clinic, we are trained to meet poverty with empathy. We are taught to identify it, to map its course as part of our care. In the streets, however, poverty often takes on a different mantle. This face of poverty demands immediate action, asking me to spare some change or a cup of coffee. This is a poverty that asks me to choose between compassion and willful ignorance. In the streets, without a stethoscope hanging around my neck and a badge to declare my status as a medical student, how am I to meet this poverty?
Several months back, I was buying food in Ottawa with a few friends at the Byward Market. It was late at night, and a man and his wife approached us, asking us for five dollars to spare. Partly to assuage my guilt, and partly to end what I felt was an uncomfortable situation, I gave them the change left over from my purchase. He negotiated and persisted with me, asking if I could give him just a few more dollars so he could buy himself and his wife their dinner. I gave them the five dollars.
Almost immediately, a man who had been watching our interaction came and offered me his full reproach. “You know what you just did? You just gave him money to buy more smokes and drugs, and he’s going to do the same thing to every customer at this spot, like he’s been doing many nights before this.” The doubt was crushing. I wondered if my compassion had been naïve and misguided.
I rationalized to my friend, although it was really for myself, that there have been studies on unconditional cash transfers to the poor showing that they reduced hunger and helped build assets, without increasing spending on alcohol and tobacco. These cash transfers came without any attachments or obligations, and relied solely on trust. My “cash transfer” was based on trust. I concluded, for my own sake, that my action was justified by evidence.
Two weeks later, a young man walked by me along a street in downtown Kitchener and asked if I have some quarters to spare. I walked past him, turned around and lied, saying that I was not carrying any change. That same weekend, I was in Toronto, and I counted six people who asked me for change, and with whom I made every effort to avoid eye contact. If I had not seen them, if I had rendered them invisible, then maybe I would not have had to confront what seemed like an inescapable moral quandary – to give or not to give.
This inconsistency is chronic to me. At best, I feel like a habitual hypocrite, alternating between periods of giving and withholding. At worst, I feel like a medical Judas, fostering dependency when I give, and undercutting my commitment towards the sick and suffering when I withhold. I try to think of what allows such inconsistency to endure outside the walls of the examination room. Is the poverty I see in the clinic truly different from the one I see in the community?
Intuitively, I know that the affirmative is impossible. The man I encountered in Kitchener could very well have walked into the clinic in which I was doing my placement. The patient who was describing his troubles at work and his substance dependency to me could have very well walked past me on the street. If patient and person are the same, then so is the poverty that beleaguers them. It is the same poverty, in a different space. And it is the space that molds my perception of poverty as it is confronted, shaping the way that I respond to it.
Through the lens of medical education and training, poverty becomes a clinical risk factor. In the clinic, there are expectations to identify the socioeconomic status of a patient, and there are interdisciplinary teams to help address poverty as part of therapeutic care. In a sense, my (future) professional obligations relieve me of the individual responsibility of having to choose between the act of sparing change and walking away. I am pushed by fiduciary duty, by ethical code of conduct and by good evidence, to spare that change, albeit in a different way. I can point indigent patients to social benefits for which they are eligible, or refer them to social workers. I cannot directly give patients money, as that infringes on professional boundaries and blurs the patient-physician relationship. My options are more limited but far clearer. The choice has been made for me.
Outside the clinic, however, the lens through which poverty is seen is stripped of its regulatory elements, forcing me to face it with the full weight of humanity. No longer are my choices restrained by professional guidelines, no longer are they de-individualized. The act is no longer between a patient and a physician, but between one person and another. There is no evidence to say what will come out of the act I choose, and there is no body to keep me accountable to the consequences. The act becomes a human one rather than a professional one. The choice is mine alone, and somehow, it feels heavier.
As a medical student, I confront the basic schisms in my own identity on a regular basis. I don my stethoscope, and channel a diagnostic, empathetic, and therapeutic persona. I remove my stethoscope, and freely take up both virtue and vice. The experience is often jarring, and I attribute my struggle to respond appropriately to poverty to this divide. But ultimately this discussion is not about me. It is about the patient who lives in poverty in both the clinic and the community. Patients do not have the luxury of splitting their identities, as I often do.
I realize that perhaps the least I can do is to apply an equal measure of empathy to the poverty I encounter in the streets. When I do give, it is because I feel that I can help the person in front of me at that time and in that moment. But when I give, I will remember that my act is only for fleeting relief, and that I need to take action in advocating for structural solutions. When I do not give, it is because I cannot afford to do so at that time. But when I do not give, I will not render the asker invisible, and I will bear witness to their circumstance. In every act, I must meet poverty with humanity, with thought, and with solidarity.