NEJM Perspective: Crossing Borders by Marlene Martin, MD

New England Journal of Medicine - Perspective

By my third time caring for John, there was a certain familiarity in our interactions. An overweight white man with salt-and-pepper hair, John was in his early 50s and lived with his father. He’d been a successful chef but struggled with an addiction to injection methamphetamines that had left him unemployed, with hepatitis C and a frail heart.

“I’m leaving,” John told me, as he lay in bed with a tray of untouched hospital food covered by empty fast-food containers and discarded bags of salty snacks. The hospital was a last resort for John. By the time he caved and came in, he was battling to breathe, his kidneys protesting, lungs drowning, and heart struggling as his body ballooned with extra fluid. As soon as he felt better, he’d rip out his lines and bolt. His chart was littered with the terms doctors use for patients they find the most difficult. Uncooperative. Leaves against medical advice. Nonadherent. Volatile. These phrases bias providers before they even lay eyes on the patient.

John’s newest declaration of departure didn’t shock me, but the reason did. It was November 7, 2016, he reminded me, and with the election the following day, he needed to work the polls. But I knew John didn’t feel well, because he promised me he’d come back as soon as the election results rolled in.

In another country, I might not have become a doctor. My parents immigrated to the United States from Mexico without papers in the late 1970s. The oldest of his siblings, my father dropped out of school after sixth grade to work in the mercado making juices. At 17, still barely affording solid meals after a decade of nonstop labor and unable to envision an alternative future, he headed north, nearly drowning in the Rio Grande on his third attempt at crossing the border.

My mother was given away to relatives because her father had died before she was born. She worked for her room and board as a cook, babysitter, and housecleaner. When she finished high school, she left Mexico to meet her sister in California, where she met my father, her hard-working neighbor in Inglewood. My father dreamed of returning to Mexico to start a small business, but my mother convinced him to use their savings on a down payment for a house instead. They moved into a home that would remain unfurnished for the next 2 years with me, their newborn.

When my siblings and I were growing up, my dad drove trucking routes, hauling dead animals from veterinarians and city pounds to the crematoria. On overnight trips, he disappeared for days and rarely worked less than 80 hours, 6 days a week. For 34 years now, he has done this, with little change except worsening deformities in his hands and deepening crevasses in his sun-drenched face.

My mother worked at a patch-making factory until the cost of babysitters outweighed her paycheck. But we were poor, so she never really quit working. My mom was savvy: a talented cook, eschewing recipes, who to this day can whip up a feast for 50 at a day’s notice; a feminist, sending her three daughters (and son) to college despite her father-in-law’s disapproval; and a tireless volunteer at the local Catholic school so she could afford our tuition. As children, we loved to sit in the living room and watch Sister Act 2 while my mom cooked dinner, and I can still vividly hear her declaring in the best Spanish impersonation of Whoopi Goldberg she could muster, “If you want to be somebody, if you want to go somewhere, you better wake up and pay attention.”

One day, when I was 9, I answered the doorbell to find three men in serapes, backpacks slung over their shoulders, exhausted and famished. I felt scared facing the strangers and ran to fetch my mom. They were immigrants who’d just crossed the border in search of a better life, she told me, people like us. “No one becomes poor by giving,” she said, as she cooked them dinner and slipped them money, “and we can always add more water to the beans.”

Memories like these have multiplied in my waking thoughts and nightly dreams since the 2016 election. I think of my own life and those of my siblings. If my parents had not made the perilous journey north before the Reagan amnesty law passed, they wouldn’t have the green cards or citizenship they now hold. Instead, they’d face walls, fear, and deportation, and I’d be telling a story of impossibilities.

The day after the election, John was back, with a grin I’d never seen him wear before. “Trump won!” he exclaimed. His efforts, John told me, had paid off.

I’d spent the previous night in tears, and in that moment I felt faint, struggling to hold back the well that still remained. I wanted to walk out of the room, to yell that I was the daughter of Mexican immigrants as well as the doctor caring for him at the county hospital — a job I’d taken because I wanted to care for people like him: patients on Medi-Cal and disability, the disenfranchised and the struggling, on whom much of society had given up. I wanted to tell him that neither a wall nor the dismantling of Obamacare would serve his interests. I wanted him to see the solidarity our situations warranted.

I said none of this. I took a deep breath and told John that I was happy he’d returned. I’d take excellent care of him, I said, and I meant it. In the safety net, we often go far beyond our written obligations or prescribed hours.

My sadness since election night hasn’t abated, and my feelings have only been intensified by reminders in my life and in the news. I feel sad that my colleague’s 6-year-old patient has nightmares and urinary incontinence because she is terrified her parents will be deported. Sad that my patients fear coming to the hospital despite grave illness out of panic that someone will ask about their immigration status. Sad that students covered by the Deferred Action for Childhood Arrivals (DACA) program have no idea what their future holds. Sad that families are splintered, torn apart, separated by countries or continents. Any of these stories could have been mine.

But I also feel pride in everything that countless immigrants and their children contribute to this country. My immigrant background forged me, and I treat my patients with relentless dedication not only as a physician but also as a first-generation, bilingual and bicultural Mexican-American woman. My parents’ sacrifice, hard work, and hunger for opportunity ignited within me the desire to become a doctor to those whose lives have not been easy — to the immigrants, homeless, mentally ill, and people with addictions. I care for John not in spite of my Mexican heritage but because of it.

A few weeks later, I was leaving clinic when someone hollered my name from across the room. “Dr. Marlene!” John shouted, as he walked over and embraced me. “Thank you for taking care of me. I know you really care about me, and I’m sorry I’m so difficult,” he said. I walked out, blinking, into the afternoon light.

 

From the Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, and the Department of Medicine, University of California, San Francisco School of Medicine — both in San Francisco.