The Social Determinants of Health

2010
LaBella, Lisa

You may have heard about a young Eritrean newcomer, nineteen years old, who was stabbed to death in downtown Winnipeg mid-March of this year. My sense is that the death of Abdul Jemei has hit many of us in the wider community particularly hard, even though we are barraged with reports of stabbings, beatings and shootings almost daily in these parts.

Abdul was by all accounts what you’d call a ‘good kid’ --a popular high school student able to resist the lure of gangs that prey on immigrants, a good worker at the pizza franchise where he worked to help his parents support six brothers and sisters, a young man who earmarked his next paycheque to take his little brothers to the movies. In short, he had what we’d wish for all Canadian kids: a strong character, a sense of responsibility, a loved and loving family.

He and a friend were downtown on a weekday evening near the ‘Y’ around 9:pm.They were both stabbed. Abdul didn’t survive.

I never met Abdul, but his mother Sofia is familiar to me as the kindly woman who cleans the floors in the research institute where my dad has his lab. I immediately warmed to her when we met, in part because of my soft spot for the people of East Africa where I’d travelled in my youth, and partly because I’ve gotten to know so many African patients at the downtown clinic where I work. You just say: Hello, how’s it going? to Sofia, and her whole face smiles; a smile emblematic of how people of her culture respond to even our most fleeting acknowledgements. And though such smiles will quickly erupt into full-blown laughter if you supply an additional small joke or similar prod, until you crack open the door, they carry the most graceful air of reservation. They are, generally speaking, one of the most polite, warm, and gracious patient populations I have ever encountered. And in light of the rock-hard road they travelled to get here, that does amaze. Having now met hundreds of Ethiopians, Eritreans and their neighbours in the examination room, it is clear that before atrocities, traumatic loss and displacement befell them, they were raised to have respect for others, to be open to joy.

For the past several years in Winnipeg, annual quotas for incoming refugees were largely met by planeloads of newcomers from several East African regions. ‘Newcomers’ as they are so sweetly called is also how they refer to themselves, and they are housed downtown upon arrival close to where I work. Now for some absurd reason, these planeloads have frequently arrived in February - when the weather couldn’t be any crueller, the streets of downtown Winnipeg any darker. You must feel you like you’ve landed on a different planet! I learned to say, often through a translator, to new arrivals sitting politely in their gloriously coloured traditional clothes, me in my dingy black pants and shapeless lab coat. Breaking into smiles and laughter without exception at this ice-breaker, they reply: Yes, yes, I do! And if there’s a translator involved, he or she is laughing too.

And then, before getting down to the actual aches and pains that brought them in, I steal a chance to bond a bit further by trying to name the closest place I’d ever been to their original home. And if they’re from Addis Ababa or refugee camps in Uganda or Kenya I really luck out, as they usually speak English then, and away we go -- the invisible wall between African refugee and Canadian doctor virtually melting on the exam room floor. Not infrequently a female patient becomes so animated at what is evidently my unexpected friendliness she’ll gently touch my knee with her hand as I sit pointed towards her or stretch out her arms for a hug. I know through the touch and laughter we are jointly embracing the absurdity of it all ... how we can all have come from anywhere, travelled anywhere, end up anywhere; yet across a whole Rift Valley of our differences in the dead of a Canadian winter, warm each other’s souls.

But one doesn’t need to have travelled to Africa or have worked directly with immigrants to be deeply, deeply pained by Abdul Jemei’s death. We know his family escaped from the politically complex and war-stricken region of Ethiopia, Eritrea and Sudan; that they would have endured unimaginable stress just to keep the family intact, healthy and safe; and that they did this while transitioning to a foreign land with its frigid temperatures, new language, and fast-paced consumer culture that I find even myself, difficult to embrace or understand.

And as hosts, our guilt is obvious and of the highest order since this is our home where this family sought refuge but lost their son. And it pains us that we could see coming even before we were told, that the suspect in custody would likely be a youth, ‘previously known to police’ -- with odds better than they should be of being aboriginal, with a drug problem, and/or Fetal Alcohol Spectrum Disorder (FASD). Winnipeg has an FASD ‘problem’ of such magnitude it cannot be extricated from the crime load we endure: countless kids navigating life in the most chaotic, undereducated families in the poorest parts of town, with the fewest resources to help them. In medical school they called these life descriptors ‘the social determinants of health’ and these kids who have the least neurobiological means to do so, are challenged by the worst of them.

So what does each of us do? In my case, I’ve felt so overwhelmed by the degree of drug-seeking and associated ‘life-mess’ at my downtown clinic job that I took several months training in addictions last year and now work part-time as a ‘methadone doctor’ at a brilliant full-program clinic. I’ve learned that while, indeed, some people get hooked on narcotics during pain management or misguided recreational use, most of the difficult cases started out with self-medication of various psychological disorders or the emotional pain from early-life trauma. I’ve also learned first-hand what crimes are committed to pay for expensive oxycontin or non-opiate habits; how an unlikely person in significant withdrawal might hold up a pharmacy or slide into prostitution. Fortunately, the majority do stabilize on methadone and the chaotic world of each individual addict really does calm down and so the impact on the world at large. This is true even in a city like Winnipeg where you can feel the wind blow through that widening gap between the rich and the poor - a root cause when you get right down to it of pervasive urban violence resulting in tragedies like the killing of Abdul. Ah yes, the social determinants of health; the social determinants of life.

Theme: Death and Dying | Décès et le mourir
Theme: Family | Famille
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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