A Childless Motherhood

Well of course! Did we think there would be no consequences? Did we actually think we could get away with it? That there weren’t two sides to the story that we all needed to hear?

Sometimes I think we are so focused on our journey to right a wrong, that we wander off the path to those we hope to save. Things are too partitioned -a modern day rendition of the biblical Matthew 6:3 where the left hand does not know what the right hand is doing… Or, perhaps, is not doing.

If one side of a page seems to contain all the information I seek, I may miss what’s written on the back. I feel no need to turn it over. An article in the Conversation turned the page for me:

https://theconversation.com/losing-children-to-foster-care-endangers-mothers-lives-93618

The author, Elizabeth Wall-Wieler, a PhD student in Community Health Sciences at the University of Manitoba, writes that ‘Mothers whose children are placed in foster care are at much higher risk of dying young, particularly due to avoidable causes like suicide. When a child is placed in foster care, most of the resources are focused on the child, with little to no support for the mothers who are left behind.’

In retrospect, of  course, it seems obvious -the mother-child bond is not something easily missed, and whether or not we attribute it to physiological changes such as oxytocin levels in her blood, or less reductionist, atavistic mechanisms, it is a powerful thing, dismissed only at her -and our– peril.

The author was involved in two large studies, one of them published in the Canadian Journal of Psychiatry, which ‘[…] looked at suicide attempts and suicide completions among mothers whose children were placed in care.

‘In this study, we compared rates of suicide attempts and suicides between 1,872 mothers who had a child placed in care with sisters whose children were not placed in care. We found that the rate of suicide attempts was 2.82 times higher, and the rate of death by suicide was more than four times higher for mothers whose children were not in their custody. […] Mothers whose children are taken into care often have underlying health conditions, such as mental illness and substance use. In both studies, we took pre-existing health conditions into account, so that was not the reason for the higher mortality rates we found.’

And, the author feels, ‘Most legislation pertaining to child protection services indicates that families should be supported, but the guidelines around what is expected of the child welfare system when it comes to the biological mothers are not clear. The main role of social workers is to ensure that the child is doing well. Social workers are already so busy, so it is often hard for them to justify spending their limited time to help mothers resolve challenges and work with them to address their mental and physical health needs.’

Other studies have also addressed the issue of sending children to foster care: ‘A study in Sweden found that by age 18, more than 16 per cent of children who had been in foster care had lost at least one parent (compared to three per cent of children who had not been in foster care). By age 25, one in four former foster children had lost at least one parent (compared to one in 14 in the general population). This means that many children in foster care don’t get the chance to be reunited with their families.’

I thought that the whole idea of fostering a child was care and sustenance until a more permanent placement was achieved or, ideally, the birthparent was able to reassume custody. This is perhaps more likely if the child can be placed with members of the same family -grandmothers, aunts, etc.- but even then, if the mother does not receive adequate support and treatment for the condition that led to the apprehension of her child, the results are apt to be the same.

In Canada, it seems, the mothers most affected are those from the indigenous community -our First Nations. The Canadian Minister of Indigenous Services, Jane Philpott, addressed indigenous leaders about this issue at a two-day emergency meeting on Indigenous Child and Family Services in Ottawa in January, 2018. http://www.cbc.ca/radio/thecurrent/a-special-edition-of-the-current-for-january-25-2018-1.4503172/we-must-disrupt-the-foster-care-system-and-remove-perverse-incentives-says-minister-jane-philpott-1.4503253 ‘The care system is riddled with “perverse incentives”. Children are being apprehended for reasons ranging from poverty to the health and addiction issues faced by their parents. In some provinces, rules around housing mean that your children can be taken away if you don’t have enough windows. “Right now dollars flow into the child welfare system according to the number of kids that are apprehended.” […] If financial incentives were based on “how many children we were able to keep in homes, how well we were able to support families — then in fact there would be no financial reason why the numbers would escalate.”’

But it’s not too difficult to read something else into all of this, of course. Uncondoned behaviour -behaviour frequently associated with poverty or marginalization- is often penalized isn’t it? Sometimes it is as simple as avoiding the transgressing community, further marginalizing it, but increasingly it is intolerance. Refusal to address the underlying issues. Not even trying to understand.

I admit that it is a difficult journey, and the road that winds between the abused child and its troubled parent is fraught. To empathize with the mother when her conduct may have been so clearly unacceptable, is seen as anathema. And yet, an attempt to understand is not a plea for condonation, merely a search for a solution. Nobody should get away with family neglect -but nothing happens in a vacuum. And there are always unintended consequences, aren’t there? Even our best intentions miss something in retrospect -solve one problem, create another. Our focus is often far too narrow -helping one person misses the one standing beside her.

Perhaps it’s time for us to stand back. As Ms Wall-Wieler puts it, ‘Specific guidelines need to be put in place to make sure that mothers are supported when their child is taken into care. This would improve the chances of reunification. And, by virtue of being a human worthy of treatment with dignity, mothers deserve support, even if it does not directly relate to how she interacts with her child(ren).’

‘Of the good in you I can speak, but not of the evil.
For what is evil but good tortured by its own hunger and thirst?’
Kahlil Gibran

 

 

 

 

 

 

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In choice, we are so oft beguiled

It’s interesting just how important categories are in our lives, isn’t it? I mean, let’s face it, often they’re just adjectives –subordinate to their nouns. Add-ons. And yet, they can frame context, colour perception, and even determine value. Some, like, say, texture or odour may be interesting but trivial; some –size, or cost, for example- may be more important although optional in a description. There are, however, categories that seem to thrust themselves upon an object and are deemed essential to its description, essential to placing it in some sort of usable context. To understanding its Gestalt. These often spring to mind as questions so quickly they are almost automatic. Gender is one such category, age, perhaps another. And depending, I suppose on the situation, the society, or even the category to which the listener belongs, there may be several others that are deemed necessary to frame the issue appropriately.

The automaticity of a category is critical, however. If the category is felt to be of such consuming importance that it needs to be established before any further consideration can be given to the object, then that object’s worth –or at least its ranking- is contingent. It is no longer being evaluated neutrally, objectively. It comes replete with those characteristics attendant upon its category –intended or not. Age, for example, wears certain qualities, incites certain expectations that might prejudice acceptance of its behaviour. Gender, too, is another category that seems to colour assumptions about behaviour. So, with the assignation of category, comes opinion and its accompanying attitude.

One might well argue about the importance of these categories, and perhaps even strategize ways of neutralizing their influence on reactions, or subsequent treatment. The problem is much more difficult if knowledge of the category is so necessary it is intuitively provided as part of what is necessary to know about, for example, a person.

I suspect that in my naïveté, I had assumed that foreknowledge of many of these categories was merely curiosity-driven. Politeness oriented. Important, perhaps, so that I wouldn’t be surprised -wouldn’t embarrass the person at our initial encounter. But I am a doctor, and maybe see the world from a different perspective. A piece in the BBC, however, made me realize just how problematic this automaticity had become. How instinctive. http://www.bbc.com/future/story/20130423-is-race-perception-automatic?ocid

The article dealt mainly with its effects on racism, and the difficulties of countering it if we accept, as some evolutionary psychologists seem to believe, that it is basically intuitive. Evolved for a reason. Wired-in. ‘[…] if perceiving race is automatic then it lays a foundation for racism, and appears to put a limit on efforts to educate people to be “colourblind”, or put aside prejudices in other ways.’ But, as Tom Stafford, the author of the BBC article puts it, ‘Often, scientific racists claim to base their views on some jumbled version of evolutionary psychology (scientific racism is racism dressed up as science, not racisms based on science […]). So it was a delightful surprise when researchers from one of the world centres for evolutionary psychology intervened in the debate on social categorisation, by conducting an experiment they claimed showed that labelling people by race was far less automatic and inevitable than all previous research seemed to show.

‘The research used something called a “memory confusion protocol” […] When participants’ memories are tested, the errors they make reveal something about how they judged the pictures of individuals. […] If a participant more often confuses a black-haired man with a blond-haired man, it suggests that the category of hair colour is less important than the category of gender (and similarly, if people rarely confuse a man for a woman, that also shows that gender is the stronger category). Using this protocol, the researchers tested the strength of categorisation by race, something all previous efforts had shown was automatic. The twist they added was to throw in another powerful psychological force – group membership. People had to remember individuals who wore either yellow or grey basketball shirts. […] Without the shirts, the pattern of errors were clear: participants automatically categorised the individuals by their race (in this case: African American or Euro American). But with the coloured shirts, this automatic categorisation didn’t happen: people’s errors revealed that team membership had become the dominant category, not the race of the players. […] The explanation, according to the researchers, is that race is only important when it might indicate coalitional information – that is, whose team you are on. In situations where race isn’t correlated with coalition, it ceases to be important.’

I don’t know… To me, this type of experiment seems so desperate to appear to be wearing a scientific mantle, that it comes across as contrived –kludged, if you’ll permit an equally non-scientific term. But I take their point. If there is some way of diffusing the automaticity of our categorizations –or at least deflecting them into more malleable descriptors –teams, in this case- perhaps they could be used as exemplars –wedges to mitigate otherwise uncomfortable feelings. Placeboes –to put the concept into more familiar language for me.

Stopgaps, to be sure, and not permanent solutions. But sometimes, we have to ease into things less obtrusively. Less confrontationally. A still-evolving example -at least here in Canada- might be gender bias in hockey. Most Canadians have grown up exposed to hockey, and might be reasonably assumed to have an opinion on the conduct of games, players, and even rules. And yet, until relatively recently, the assumption was that hockey players –good ones, at least- were male. For us older folks, it was automatic. No thought required; no need to ask about gender. But no longer is that the case. For a variety of reasons, there is still no parity, and yet it is changing –slowly, perhaps, but not conflictually. And so, despite any initial challenges, is likely to succeed.

Am I really conflating success in the changing mores of hockey with gender equality? Or basketball teams and how we view their members, with racial equality? Am I assuming that diminishing discrimination in some fields leads to wider societal effects? Yes, I suppose I am. A blotter doesn’t care about the kind, or the colour, of the ink it absorbs; it’s just what it does. What it is. And, in the end, isn’t that what we all are, however vehemently we may protest? However much we may resist the similarities that bind us in relationship for fear of losing our own identities?

But if we step back a little, we may come to appreciate that the correlation need not be like that of a blotter -need not involve a team, or a marriage… I am reminded of the advice from one of my favourite writers, the poet, Kahlil Gibran: Love one another, but make not a bond of love: let it rather be a moving sea between the shores of your souls.

It’s the way I prefer to see the world, anyway…

Our remedies oft in ourselves do lie

I sometimes wonder if in another life I was actually a woman –perhaps in one of those what-if lands that we whisper to our children as they are nodding off to sleep. A place where roles are not so much reversed as fluid –changing as necessary, dissolving when needed. Not a perfect place –even a child expects some inequalities, some inevitable disputes- but a place where things even out in the end. Where disagreements are resolved, and fairness, like dust motes in a sunny room, coats even the darkest corners if you decide to look.

And why a woman? In this heavily gendered world, why would I espouse the mysterious side –the other side- when, for now at least, I find myself in an advantaged role? Why, if I have never entertained the idea in any but an intellectual sense, with no real desire to change my here-and-now, nor any wish to partake of other than a thought-experiment, would I think that in a once-upon-a-time story, I might have been what I am not?

I suppose, in part, it is because of the inequities to which many of us with a Y chromosome have so successfully adapted -swept under the carpet in our attempts to fashion the world in our own image. Like the sound of traffic that becomes barely noticeable to city dwellers, we have become myopic to all that isn’t immediately relevant to our own vicinity -our Lebenswelt. And it just seems so unfair.

I don’t want to sound too naïve in my jeremiad, too Pollyannoid in my expectations, but I do expect actions to be judged by what they achieve, not by who performs them. I do not expect a litany of excuses, or worse, a denial that excuses are even necessary.  As a recently retired obstetrician/gynaecologist, perhaps I am overly attuned to the denizens of my former world, but I find myself disheartened by examples of their contributions being overlooked, or at least undervalued. An article that I came across one day, outlined some of the problems: https://theconversation.com/womens-ngos-are-changing-the-world-and-not-getting-credit-for-it-88360

It discusses the role of non-governmental organizations (NGOs) in various countries –although this article specifically examines women’s NGOs and their work in India and Tanzania. ‘NGOs work with governments, community groups and the private sector — to develop and implement programs, monitor and evaluate their progress and help train people working on those projects.’ It would seem that these ‘[…]women’s NGOs played crucial roles in development projects, often mobilizing, organizing and building projects that otherwise would never have launched.’

In India, for example, ‘Women’s NGOs also conducted research to determine whether local communities could afford to pay for basic urban services. They negotiated subsidies, fair pricing and flexible terms of payment with utilities on behalf of marginalized people. They arranged access to loans from micro-finance institutions for households that could not cover the cost of water or electricity connections. And by insisting that water and electricity bills be issued in the names of female heads of households, women’s NGOs strengthened women’s access to property and housing.

‘The NGOs also educated stakeholders about the realities of life for the urban poor, and shared lessons learned in one urban area with NGOs in other cities in India.’

But, the success of their interventions often led to the marginalization of the NGO’s role in whatever successes they’d achieved. ‘[…] women’s NGOs had made vital contributions to the success of development projects, but they were easily marginalized and trivialized once those projects got off the ground. In India, after the success of the pilot projects, the other partners declared that they would “go it alone” and no longer involve the NGO partner in delivering basic urban services.’ Of course, the idea is to encourage self-sufficiency so the NGO can back away, but in many situations, their contributions, as women, were minimized in favour of the usual power brokers. ‘Although the contributions made by the women’s NGOs were critical to the existence and success of the initiatives, they were often dismissed as supplementary and dispensable by the other partners. Because the NGOs’ role of organizing, mobilizing and helping local communities participate in development initiatives was seen as a “natural” extension of women’s care-giving work, it was easy for other partners to diminish and dismiss their contributions. And because the other partners did not fully appreciate the contributions of the women’s NGOs, they were unwilling to share credit for the success of the project.’

The authors -Dr. Bipasha Baruah, Professor & Canada Research Chair in Global Women’s Issues, Western University and Dr. Kate Grantham Research Associate, International Development, McGill University- suggest  some strategies ‘to strengthen and validate the role of women’s NGOs in development partnership projects: A memorandum of understanding (MOU) that defines the specific roles and responsibilities of each partner should be an essential requirement for multiple-stakeholder projects. The lack of such formal agreements entrenches the perception that the role NGOs play is not particularly valuable.’

Call me naïve, but it is dismaying, to say the least, that such formalities are required to validate a helping hand -almost like requiring a contract be drawn up before helping someone cross a busy street.

And yet, as the authors point out, ‘It’s unfortunate they must “justify” their long-term involvement in such initiatives, but it may be incumbent upon them to make their contributions to the project more visible to the different partners and to the development community at large.’ And perhaps more especially, ‘[…] the specific challenges and opportunities that NGOs working on gender equality, or those that define themselves as feminist NGOs or women’s NGOs, face — when participating in multiple-stakeholder projects.’

Okay I understand, I guess. Let’s see… Outside agencies have to help women help each other, because otherwise the communities will forget who helped them. No, that can’t be right… Okay then, outside agencies have to publicize the fact that women are able to help… Uhmm, no? Well then, how about the agencies claim credit for facilitating the things that women have been doing for millennia…

I’m clearly getting old and cloistered in my years. Many of those things I had once assumed were self-evident, I now find were merely wide-eyed hopes -inexperienced beliefs, as devoid of truth as the fairy-tales I told my children. I have obviously not tasted all that I am supposed to sample despite my age –and yet, I still believe that help knows no gender. Goodness is not biased, nor is succour credited only to those crowding around and pointing at themselves when the patient is finally ready to be discharged.

But, perhaps I read too much poetry, too much Kahlil Gibran, when I was young; perhaps you cannot believe poetry; perhaps it is simply not enough –even if it speaks truth to power:
‘there are those who give and know not pain in giving, nor do they seek joy, nor give with mindfulness of virtue; they give as in yonder valley the myrtle breathes its fragrance into space. Through the hands of such as these God speaks, and from behind their eyes He smiles upon the earth.’

 

 

 

 

 

 

 

 

 

 

 

The Feminist Egg

Once upon a time, I suppose that one of the characteristics of Age was its hubris. After a certain age, it was easy to dismiss most new things as mere variations on time-tested themes –additions, clever perhaps, intriguing even, but still accretions. Ecclesiastes lived in old minds: The thing that hath been, it is that which shall be; and that which is done is that which shall be done: and there is no new thing under the sun. And yet nowadays, even the quickest peek over the shoulder calls that into question. Maybe it always did, but without the publicity it now entertains.

New things –truly new things- are often the hardest to accept, especially if they fly in the  face of cherished beliefs sufficiently entrenched as to be regarded as not merely true, but obviously true -common sense, in fact. It took generations to accept evolution –and now it seems only sensible that the random acquisition of those traits that help survival will be the ones selected for in the next generation. It was not an upwardly purposeful spiral that inevitably led to homo sapiens; evolution doesn’t change cows to humans –it just eventually creates cows better able to survive in whatever milieu they find themselves. And randomly –the unfit are still granted existence, but if they are not suited, they pass on little benefit to their progeny.

It’s true that animals –mammals, especially- do attempt to influence desirable traits in their offspring by choosing healthy partners exhibiting those characteristics. Hence various mating rituals and dominance contests amongst the males; hence elaborate male bird plumage, presumably a proxy, recognizable by a receptive female, as indicative of a primus inter pares. And yet it was probably regarded as curious in premodern societies that a female would be accorded any important choice, let alone that of selecting what she wanted in a partner. Although there has always been a cadre of women who have made their marks throughout recorded history, the examples are sadly limited –curtailed no doubt, because it was usually men writing about what they felt was important to document.

Fortunately, times are changing, as is the realization that each side of the gender divide is equipotent. Just how fluid the roles are is a constant source of wonder to me. Even in these days of Darwin, I am amazed at the still unsuspected porosity of the envelope. And while it no longer seems unusual or unlikely that an information-processing organism like, say, a bird might be able to select an appropriately endowed mate based on observable clues, it is still surprising –to me, at least- that selection duties might be conferred on a more microscopic scale: on an egg, for example.

I first encountered this idea in an article from Quanta Magazine: https://www.quantamagazine.org/choosy-eggs-may-pick-sperm-for-their-genes-defying-mendels-law-20171115/  I have to say it reminded me of Hamlet’s rejoinder to the sceptical Horatio on seeing Hamlet’s father’s ghost: ‘There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.’

The competition in sexual selection was thought to be pre-copulatory –‘After mating, the female had made her choice, and the only competition was among the sperm swimming to the egg. This male-oriented view of female reproductive biology as largely acquiescent was pervasive, argued Emily Martin, an anthropologist at New York University, in a 1991 paper. “The egg is seen as large and passive. It does not move or journey but passively ‘is transported’…along the fallopian tube. In utter contrast, sperm are small, ‘streamlined’ and invariably active,” she wrote.

‘Beginning in the 1970s, however, the science began to undermine that stereotype. William Eberhard, now a behavioural ecologist at the Smithsonian Tropical Research Institute, documented all the ways that females can affect which males fertilize their eggs even after mating.’ For example, ‘Internal fertilizers have their own methods of what Eberhard dubbed “cryptic female choice.” Some female reproductive tracts are labyrinthine, complete with false starts and dead ends that can stymie all but the strongest sperm. Some females, including many species of reptiles, fish, birds and amphibians, that copulate with more than one male (which biologists estimate are a vast majority of species) can store sperm for months, even years, altering the storage environment to stack the odds to favor one male over another. Many female birds, including domestic chickens, can eject sperm after mating , which lets them bias fertilization in favor of the best male.’

The plot thickens. These strategies seem only to select whose sperm to allow access to the precious as-yet unfertilized eggs. But even sperm from the same individual can vary. So, are things just left to chance? Are we still talking Darwin here? And are the combination probabilities proposed by Mendel that depend on randomness still in the picture?

It would seem that the egg itself may have a say in which sperm it uses, and that unlike the voting system in many democracies, it may not be just the ‘first past the post’ -the marathon winner- who gets the prize.

The article presents several theories as to how the egg may be able to ‘choose’, but as yet there seems to be no clear indication as to whether it always happens, or whether it is just able to weed out some potentially damaging or clearly unsuitable ones by the signals they emit –or fail to emit… Sometimes, anyway. Mistakes clearly occur; abnormal genes do manage to slip through, leading to abnormal embryos –some of which are unable to develop enough to survive.

But that there may be yet another layer of protection built into the system –another unsuspected surveillance system- is what intrigues me. And that, once again, it seems to invest the power of a truly critical decision with the female is a cautionary tale for those who cling to the shredding coattails of androcentrism. It is simply another piece of evidence, if more were needed, that Life and all that it enables, is not a zero sum game. It is not a contest between genders, but a journey together. Still…

Let there be spaces in your togetherness.                                                                                      And let the winds of heaven dance between you.
Love one another, but make not a bond of love.
Let it rather be a moving sea between the shores of your souls.
Fill each other’s cup but drink not from one cup.
Give one another of your bread but eat not from the same loaf.
Sing and dance together and be joyous, but each one of you be
alone – even as the strings of a lute are alone though the quiver
with the same music.
Give your hearts, but not in each other’s keeping.
For only the hand of Life can contain your hearts.
And stand together yet not too near together:
For the pillars of the temple stand apart,
And the oak tree and the Cyprus grow not in each other’s shadows. –Kahlil Gibran –

I couldn’t resist.

 

 

 

 

 

For my Pains, a World of Sighs

What does pain look like? An intriguing question to be sure, but one I hadn’t even thought to ask until recently. Pain is one of those things that, like St. Augustine’s quandary over Time, presents a similar difficulty in defining. The International Association for the Study of Pain made a stab at it: ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,’ but somehow, it seems to lack the immediacy of its subject matter –it stands, like an observer, outside the issue. Poets have done a better job, I think. Emily Dickinson, for example: After great pain, a formal feeling comes. The Nerves sit ceremonious, like tombs’; or Kahlil Gibran: ‘pain is the bitter potion by which the physician within you heals your sick self’; or even Oscar Wilde: ‘Pain, unlike Pleasure, wears no mask.

But I was reminded of another of Wilde’s observations -‘We who live in prison, and in whose lives there is no event but sorrow, have to measure time by throbs of pain, and the record of bitter moments.’- when I read a CBC article from November, 2016 entitled ‘Indigenous children, stoic about their pain, are drawn out with art’ http://www.cbc.ca/news/health/aboriginal-youth-art-pain-hurt-healing-1.3852646

‘”Aboriginal children feel and experience pain just like anyone else. It’s just that they express their pain very differently,” said John Sylliboy, community research co-ordinator with the Aboriginal Children’s Hurt and Healing Initiative.

‘”They don’t necessarily verbalize their pain, or they don’t express it outwardly through crying or through pain grimaces,” he told CBC News.’

‘These children are socialized to be stoic about their pain, to hold in their pain.’- Margot Latimer, Centre for Pediatric Pain Research, IWK Health Centre in Halifax. ‘”We noticed we weren’t seeing any First Nations youth referred to our pain clinic at the IWK hospital and wondered why that was so.”‘ It didn’t make sense, she thought — especially since research shows that chronic illness in First Nations communities is almost three times higher than in the general population. Aboriginal children are especially vulnerable, says Latimer, with higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis.’

I found it very moving, and yet disturbing, that ‘[…] cultural traditions, and lingering effects from the residential school system, are some of the reasons Indigenous kids pull on their suit of armour against pain and hurt.’ But they’re children, and perhaps not yet completely shackled to all the subtleties of culture. ‘A group of Indigenous children and teenagers from four First Nations communities in the Maritimes were asked to paint their pain, to express their hurt through art. Researchers were hoping to tease out emotions from a population more inclined to show resilience to pain.’ But soon after, the children began to depict not just physical pain, but emotional pain as well. As Sylliboy points out, ‘”These kids told us about loneliness, sadness, darkness, bullying, hopelessness. It’s not the typical anxiety [or] depression. It is more complex than that.” “To these clinicians who are just asking about physical pain and not looking at emotional pain as well, it is important, because Aboriginal kids are showing us that there is no difference between emotional and physical pain”, said Sylliboy. “It’s just pain.”‘

And I learned another thing about pain –or maybe about children – ‘It’s all about creating a safe space for the children when they come to the hospital, says Latimer.  She says it’s about learning a bit about them and gaining their trust. “When they come to the health centre, or a physician or a nurse practitioner, they want to tell their story, but we do not train health professionals to assess pain that way.”’

It reminded me of a patient I first met in the Emergency Department at the hospital when I was the gynaecologist on call one night. Edie, an aboriginal woman arrived with heavy bleeding –she was  apparently in the throes of miscarrying an early pregnancy- and had brought her eight year old son to the hospital because she had no one to take care of him at home. The bleeding settled shortly after her arrival and an ultrasound in the department revealed that there was no further tissue left in the uterus, so fortunately we didn’t have to take her to the operating room. But the process of diagnosis and decision was not instantaneous. Although the little boy, Timmy, was clearly frightened, his face stayed neutral. And yet it seemed as if he was peeking through hole in a fence, and I could see his eyes carefully following my every move. One of the nurses volunteered to sit with him in the waiting room while I examined his mother, but I was the last one he stared at before leaving; I was the thing he didn’t understand.

I decided to let Edie rest on the stretcher for a while before discharge, and I thought I’d reassure Timmy before I left. He was sitting on the too-big chair as quietly and unmoving as an adult and when I approached, he stared at me like a deer hiding in a forest.

“Your mom’s going to be okay, Timmy,” I said with a big smile.

But he still seemed just as frightened, and stayed silent for a moment. “There was blood on her pants,” he mumbled, perhaps making sure I’d noticed. He allowed his eyes to venture out further into the open and he examined me again. “And she was hurting…”

What do you tell a little boy about his mother’s suffering? I knelt down on one knee in front of him so our eyes were on the same level and put a hand on his knee. I couldn’t  think of anything else to do. “She’s not hurting now, Timmy,” I said and smiled again.

He looked at my hand and then he finally smiled. “Can she go home now?” When I nodded, he reached out and carefully touched one of my fingers, and then when I didn’t pull away, he patted my hand.

I never saw little Timmy again, but a few weeks later, Edie came to my office for a follow-up visit and to thank me for seeing her in the hospital in the middle of the night. “Timmy was really impressed,” she said and smiled. She ruffled through her purse and brought out a rumpled piece of paper she’d nonetheless folded carefully. “He drew this for you, doctor,” she said proudly, and handed it to me.

When I opened it up, it was a drawing of a hand in red crayon.

“He said it was to thank you…” She seemed embarrassed, and hesitated before continuing. “I asked him why he drew it in red…” she said.

She still seemed embarrassed, so I stayed silent until she felt ready to continue.

Edie studied me for a moment with her big brown eyes, still uncertain. Then her face relaxed and a big smile appeared. “He said maybe you were one of us, now…”

I could have cried.